^ 


LIBRARY 

UNIVERSITY  OP 
CALIFORNIA 

SAM  ntr'-n 


l'lllNll^i'^INliVN^mf'^'-"'0"'^''^   SAN  DIEGO 


3  1822  00501  6589 


lOO 


University  of  California,  San  Diego 

Please  Note:  This  item  is  subject  to  recall. 

Date  Due 


v.   I 


i^ 


OCT  2  7  1994 


OUT  2  7  1994 


NQV19  RECP 


CI  39a  (4/91) 


UCSD  Lib. 


Nervous  and  Mental  Disease  Monograph  Series  No.  9. 


Studies  in  Psychiatry 


Vol.  I 


By 

Members  of  the  New  York  Psychiatrical  Society 


NEW  YORK 
The  Journal  of  Nervous   and  Mental  Disease 
Publishing   Company 
1912 


Reprinted  with  the  permission  of  the  Original  Publisher 

JOHNSON   REPRINT  CORPORATION     JOHNSON  REPRINT  COMPANY  LTD. 

1 1 1  Fiftii  Avenue,  New  York,  N.Y.  10003     Berkeley  Square  House,  London,  W1X6BA 


First  reprinting  1970,  Johnson  Reprint  Corporation 
Printed  in  the  United  States  of  America 


Copyright  1912 

BY 

The  Journal  of  Nervous  and  Mental  Disease 

Publishing  Company 

NEW  YORK 


In  the  early  winter  of  1903,  Dr.  Allen  McLane  Hamilton 
invited  a  number  of  physicians  to  spend  an  evening  with  him  for 
the  purpose  of  discussing  the  advisability  of  founding  a  society 
for  the  promotion  of  the  interests  of  psychiatry.  This  conference 
was  held  and,  as  a  result  of  it,  the  constitution  and  by-laws  of  the 
Psychiatrical  Society  of  New  York  were  adopted  on  March  2, 
1903.  The  Society  has  grown  rapidly  but  has  always  retained  its 
original  semi-private  character.  The  meetings  have  been  held  at 
the  invitation  of  individual  members,  but  any  physician  who  has 
shown  especial  interest  or  achievements  in  psychiatry  is  eligible 
for  membership.  Since  its  foundation,  four  meetings  a  year  have 
taken  place,  at  which  original  contributions  have  been  read  and 
discussions  carried  on  on  various  subjects  connected  with  psy- 
chiatry. Many  of  the  papers  have  been  published,  but  until  now 
no  attempt  has  been  made  to  collect  them  in  permanent  form. 
When  the  question  of  publication  came  up  it  was  found  that  an 
issue  of  all  the  contributions  would  be  too  great  an  undertaking. 
So  some  papers  were  chosen  foi*  publication  now,  while  others 
were  left  for  subsequent  volumes. 

Pearce  Bailey,  Chairman, 
Adolph  Meyer, 
George  H.  Kirby, 

Publication  Committee. 


m 


LIST  OF  MEMBERS  OF  THE  NEW  YORK 
PSYCHIATRICAL   SOCIETY 

Maurice  C.  Ashley   Middletown,  N.  Y. 

Pearce  Bailey    New  York  City. 

SwEPSON  J.  Brooks  Harrison,  N.  Y. 

C.  Macfie  Campbell   White  Plains,  N.  Y. 

L.   Pierce  Clark    New  York  City. 

Henry  A.   Cotton    Trenton,  N.  J. 

Charles   L.    Dana    New  York  City. 

*Emmet  C.  Dent  New  York  City. 

A.  Ross  Diefendorf   New  Haven,  Conn. 

Albert  Warren  Ferris   Albany,  N.  Y. 

Menas  S.  Gregory   New  York  City. 

Allan    McLane    Hamilton    New  York  City. 

Graeme  M.   Hammond    New  York  City. 

August   Hoch    New  York  City. 

William    Hirsch    New  York  City. 

Smith  Ely  Jelliffe  New  York  City. 

George  H.  Kirby   New  York  City. 

Phillip  C.   Knapp    Boston,  Mass. 

Robert  B.    Lamb    Fishkill-on-Hudson,  N.  Y. 

^Alexander  E.   McDonald    New  York  City. 

William   Mabon    New  York  City. 

Carlos  Macdonald   New  York  City. 

Adolf    Meyer    Baltimore,  Md. 

Flavius  Packer  New  York  City. 

Stewart    Paton     Princeton,  N.  J. 

Frederick  Peterson    New  York  City. 

William  L.  Russell  White  Plains,  N.  Y. 

Henry  R.   Stedman    Boston,  Mass. 

*  Deceased. 


IV 


CONTENTS. 


Page 

The  Insane  in  Japan.     Dr.  Frederick  Peterson i 

A  Study  in  Race  Psychopathology.     Dr.  George  H.  Kirby  9 

The  Curability  of  Early  Paresis.     Dr.  Charles  L.  Dana  17 

The  Diagnosis  of  General  Paresis.     Dr.  C.  Macfie  Campbell  41 

Clinical  Varieties  of  Periodic  Drinking.    Dr.  Pearce  Bailey  65 

A  Study  of  Some  Cases  of  Delirium  Produced  by  Drugs.  Dr.  August 
Hoch  75 

Remarks  on  Habit-Disorganizations  in  the  Essential  Deterior- 
ations, and  the  Relationship  of  Deterioration  to  the  Psy- 
chasthenic, Neurasthenic,  Hysterical  and  Other  Constitu- 
tions.    Dr.  Adolf  Meyer  95 

Constitutional  Factors  in  the  Dementia  Precox  Group.  Dr. 
August  Hoch  Ill 

Comparative  Psychological  Studies  of  the  Mental  Capacity  in 
Cases  of  Dementia  Precox  and  Alcoholic  Insanity.  Dr.  Henry 
A.   Cotton   123 

The  Relationship  of  Hysteria,  Psychasthenia,  and  Dementia 
Precox.    Dr.  Adolf  Meyer  ISS 

Ocular  Reactions  among  the  Insane.  Drs.  A.  R.  Diefendorf  and 
Raymond  Dodge 163 

Cyclothymia — The  Mild  Forms  of  Manic  Depressive  Psychoses 
and  the  Manic-Depressive  Constitution.    Dr.  Smith  Ely  Jelliflfe  193 

Ocular  Disc  Changes  in  Dementia  Pr^^cox.  Dr.  H.  H.  Tyson  and 
L.  Pierce  Clark    209 

List  of  Papers  Read  Before  the  New  York  Psychiatrical  Society.  .  209 

The  Eye  Syndrome  of  Dementia  Precox.  Drs.  H.  H.  Tyson  and 
L.   Pierce  Clark 212 

V 


THE  INSANE  IN  JAPAN 
By  Frederick  Peterson,  M.D., 

PROFESSOR    OF    PSYCHIATRY,    COLUMBIA    UNIVERSITY,    NEW    YORK 

During  a  vacation  spent  last  summer  (1909)  in  Japan,  I 
visited  a  number  of  institutions  for  the  insane,  and  through  the 
many  courtesies  of  Professor  Kure  and  Professor  Miura  of 
Tokyo  and  Professor  Imamura  of  Kyoto,  I  not  only  saw  them 
under  the  best  auspices  but  was  furnished  with  much  informa- 
tion in  relation  to  psychiatry  in  Japan  which  I  shall  briefly  put 
before  you. 

The  medicine  of  ancient  Japan,  like  its  art,  literature  and 
religion,  was  derived  from  China  by  way  of  Corea.  The  earliest 
Chinese  medical  literature  which  deals  in  any  manner  with  in- 
sanity dates  from  about  200  B.C.  The  earliest  historical  refer- 
ence to  insanity  in  Japan  is  contained  in  the  law  of  about  702 
A.D.,  which  required  the  insane,  epileptics,  lepers,  blind  and 
crippled  to  be  given  over  to  certain  official  caretakers,  who  on 
taking  such  cases  into  their  families  were  absolved  from  taxation 
and  civic  duties.  Between  these  dates  and  for  some  time  later 
Japanese  physicians  were  guided  in  their  study  and  practice 
wholly  by  Chinese  medical  books,  in  much  the  same  manner  as 
the  Europeans  for  centuries  acted  only  on  the  authority  of  Hippoc- 
rates, Galen  and  the  Arabian  writers.  Insanity  and  epilepsy  are 
well  described  in  the  first  Japanese  book  of  medicine,  the  "  Ish- 
inho,"  appearing  in  982  A.D,  For  several  centuries  after  this, 
medical  treatment  fell  chiefly  into  the  hands  of  the  Buddhist 
priests  who  practised  only  with  magic  and  prayer,  until  the  period 
between  the  seventeenth  and  nineteenth  centuries,  when  medicine 
reawakened  and  the  Japanese  physicians  out-distanced  in  all  re- 
spects their  Chinese  progenitors  and  contemporaries.  The  treat- 
ment of  insanity  during  this  period  did  not  differ  much  from  that 
of  the  more  ancient  day,  and  consisted  chiefly  of  the  sweat-cure, 
catharsis,  emetics,  thermocautery  with  moxa,  hydrotherapy,  acu- 
puncture and  at  times  blood-letting.  The  needle  and  moxa  as 
2  I 


2  THE   INSANE   IN    JAPAN 

counter-irritants  have  for  ages  been  favorites  of  both  the  Chinese 
and  Japanese  in  all  manner  of  diseases.  Hydrotherapy,  described 
in  Chinese  literature  as  long  ago  as  200  B.C.,  has  always  been  a 
preferred  method  of  treatment  among  the  Japanese.  Its  use  in 
insanity  is  described  in  the  first  Japanese  book  of  medicine 
already  referred  to  (982  A.D.), 

In  old  times  the  insane  were  for  the  most  part  kept  in  families, 
the  milder  cases  taking  part  in  work  on  the  land,  or  in  the  in- 
numerable household  crafts  of  that  people.  If  subject  to  periods 
of  excitement  mechanical  restraint  was  used,  anklets,  wristlets, 
chains,  and  solidly  built  chambers  attached  to  the  paper  houses. 
Often  in  the  country  the  patients  were  blistered  on  the  soles  of 
the  feet  to  make  them  disinclined  to  run  away. 

A  kind  of  family  care  grew  up  gradually,  sometimes  evolving 
into  a  colony  system ;  and  many  private  asylums  were  established 
long  before  any  public  asylums  such  as  we  have  in  the  West  were 
created. 

Along  in  the  early  eighties  the  first  public  asylum  in  Japan  was 
organized  and  established  at  the  present  capital,  Tokyo.  It  was 
constructed  somewhat  on  German  lines,  but  with  due  regard  to 
the  necessities  of  earthquake  architecture,  for  in  a  country  where 
an  earthquake  is  almost  an  everyday  occurrence  it  is  essential  to 
build  wisely.  The  Tokyo  asylum  consists  of  a  series  of  one- 
storied  pavilions  scattered  in  a  considerable  park.  The  German 
traces  in  construction  and  arrangement  are  of  course  due  to  the 
fact  that  the  foremost  Japanese  physicians  of  that  day  had  taken 
their  training  in  Germany,  and  the  medical  profession  was  wholly 
directed  in  all  its  undertakings  by  German  influence.  Now- 
adays with  several  universities  of  their  own  and  a  goodly  num- 
ber of  medical  faculties,  quite  equal  to  any  in  the  world,  in  which 
all  of  the  professors  and  the  tongue  spoken  are  Japanese,  they 
need  not  go  abroad  for  medical  study. 

In  the  older  buildings  of  the  Tokyo  asylum  the  usual  western 
corridor  system  prevailed,  with  numerous  single  rooms,  but  as 
time  went  on  they  began  gradually  to  remove  partitions  and  to 
convert  the  series  of  single  rooms  into  good  sized  dormitories. 
This  was  the  more  readily  possible  because  there  seems  on  the 
whole  to  be  less  excitement  among  the  Japanese  insane  than 
among  the  insane  of  other  countries.     The  extraordinary  quiet- 


THE   INSANE    IN    JAPAN  3 

ness  of  asylum  wards  in  Japan  has  been  commented  upon  by 
other  foreign  visitors.  It  doubtless  depends  upon  that  imme- 
morial training  in  the  repression  of  emotional  expression  which 
is  so  noticeable  a  feature  in  Japanese  psychology. 

In  some  of  the  newer  pavilions  they  have  European  bedsteads, 
tables  and  chairs,  but  for  the  most  part  the  furnishing  is  Jap- 
anese, thick  mattings  upon  the  floors,  thick  quilts  laid  upon  these 
mattings  for  beds  and  tiny  dwarf  tables  when  such  are  needed, 
with  no  chairs  or  other  furniture. 

The  asylum  is  lighted  by  electricity,  electric  lighting  being 
a  specialty  of  the  Japanese  everywhere  at  present,  owing  to  un- 
limited waterpower  in  innumerable  mountain  torrents  which  have 
been  harnessed  to  do  this  work.  There  is  provision  for  the  daily 
hot  bath  for  every  inmate  according  to  Japanese  custom,  for 
every  man,  woman  and  child  in  Japan  takes  at  least  one  hot  bath 
a  day,  and  sometimes  two  or  three ;  and  our  western  systems 
of  plumbing  for  bath  and  toilet  purposes  have  been  adopted 
and  installed.  There  is  provision  also  for  the  prolonged  bath 
which  has  so  much  vogue  with  us  at  present  in  the  treatment 
of  the  insane. 

Much  is  made  of  occupation.  The  laundry  and  garden  work 
are  done  by  inmates.  There  were  rooms  in  which  patients  were 
weaving,  plaiting  straw,  making  paper  envelopes,  and  carrying  on 
other  crafts. 

All  the  buildings  were  airy,  neat  and  clean,  and  to  me  a  strik- 
ing feature  of  the  care  of  the  insane  was  the  morale  of  the  nurs- 
ing staff.  I  believe  such  gentleness,  kindness,  patience,  and 
assiduous  attention  to  the  sick  could  be  found  nowhere  else,  for 
nowhere  else  exists  a  whole  race  of  people  who  never  scold, 
quarrel  or  manifest  impatience,  but  always  turn  a  smiling  face 
and  extend  a  helpful  hand  to  one  another.  This  other  fact  in 
Japanese  psychology  I  observed  among  all  classes  throughout  my 
visit.  It  was  particularly  noticeable  where  I  least  expected  it, 
among  the  lower  classes. 

The  insanity  clinics  of  the  university  are  held  here  and  the 
laboratories  of  the  asylum  are  well-equippd  with  pathological 
and  psychological  apparatus.  Elaborate  histories  of  the  patients 
are  taken  and  besides  the  director,  Professor  Kure,  there  are  ten 
physicians  working  in  the  hospital  whose  capacity  is  about  500 


4  THE   INSANE   IN    JAPAN 

beds — a  capacity  of  one  to  fifty.  We  are  lucky  in  New  York 
State  to  have  one  physician  to  two  hundred  patients. 

There  can  be  no  overcrowding  in  the  Tokyo  asylum,  for 
according  to  law  a  new  patient  is  only  admitted  when  there  is  a 
vacancy.  An  indigent  patient  brought  before  the  authorities  is 
sent  at  public  expense  to  one  of  the  seven  private  asylums  in 
Tokyo  if  the  government  asylum  has  no  bed.  These  seven 
private  asylums  have  a  capacity  of  about  one  thousand  beds 
between  them. 

The  method  of  commitment  is  simple.  When  a  case  of  in- 
sanity develops,  a  member  of  the  family  reports  it  to  the  police. 
A  doctor  then  goes  to  the  house  with  the  police  officer  to  examine 
the  patient  and  reports  his  findings  to  the  head  of  the  police  who 
issues  an  order  of  commitment.  In  the  country  a  governor's 
certificate  takes  the  place  of  police  commitment.  There  is  never 
any  effort  on  the  part  of  patients  to  escape. 

The  Tokyo  institution  has  one  of  eleven  psychiatric  clinics  in 
Japan.  I  believe  we  have  not  so  many  in  the  United  States. 
There  are  psychiatric  clinics  at  the  three  universities  Tokyo,  Nag- 
asaki and  Fukuoka,  and  at  the  medical  schools  of  Okayama, 
Kawazawa,  Kyoto  (two  medical  colleges),  Nagoya,  Shibu,  Sendai 
and  Osaka. 

As  regards  the  character  of  the  cases  observed  in  Japan,  there 
are  several  interesting  points.  In  the  first  place  the  classification 
approximates  very  closely  to  ours  and  we  observe  large  numbers 
of  cases  of  dementia  prgecox,  manic-depressive  insanity,  general 
paresis,  and  the  like.  True  paranoia  as  we  know  it  is  a  great 
rarity.  On  the  other  hand  general  paresis  and  dementia  praecox 
are  more  common  than  with  us.  At  the  Tokyo  asylum  the 
proportion  of  cases  of  general  paresis  from  the  years  1887  to  1901 
was  15.86  per  cent. 

In  a  country  which  has  no  opium  or  alcohol  vice,  inebriety 
cases  are  rare.  Only  6.65  per  cent  of  the  admissions  of  men 
presented  mental  disorder  due  to  alcohol.  A  case  of  alcoholic 
insanity  in  women  is  almost  unknown.  Very  few  doctors  in 
Japan  have  even  seen  a  case  of  delirium  tremens.  Korsakoff's 
psychosis  has  not  been  observed.  The  alcohol  cases  are  due  to 
sake,  a  mild  kind  of  sherry-flavored  wine,  derived  from  rice. 
Only  the  lower  classes  drink  sake  to  excess,  and  very  few  of 


THE   INSANE    IN    JAPAN  5 

these.  Temperance  societies  are  growing  rapidly  in  Japan.  In 
Formosa,  a  province  of  Japan,  considerable  opium  is  used,  but 
scarcely  any  in  Japan  itself.  There  are  no  cases  of  Indian  hemp 
or  cocaine  inebriety.  I  noted  a  considerable  number  of  cases  of 
insanity  wholly  new  to  me,  viz :  psychoses  associated  with  Kakke 
or  beri-beri.  The  multiple  neuritis  and  mental  symptoms  made 
a  picture  something  like  that  of  Korsakow's  psychosis.  In  our 
western  books  on  nervous  diseases,  mental  symptoms  are  not  de- 
scribed at  all  as  associated  with  beri-beri,  but  in  Japan  we  have 
a  beri-beri  psychosis  which  reminds  one  partly  of  pellagrous  in- 
sanity and  partly  of  the  Korsakow  syndrome. 

I  come  now  to  the  most  interesting  part  of  my  journey  of 
observation  in  Japan. 

About  seven  miles  from  Kyoto,  one  of  the  ancient  capitals  of 
Japan,  lies  the  village  of  Iwakura,  to  which  one  day  Professor 
Imamura,  professor  of  Psychiatry  in  the  University  of  Kyoto, 
conducted  me.  It  is  alone  well  worth  going  to  Japan  to  see.  I 
believe  I  am  the  second  westerner  who  has  been  there,  the  first 
having  been  Dr.  Stieda  of  Russia  who  mentions  it,  and  calls  it  a 
Japanese  Gheel  in  an  article  on  "  Psychiatry  in  Japan "  in  the 
Centralb.  f.  Nervenh.  und  Psychiatric  for  1906.  Professor  Ima- 
mura has  himself  described  it  in  the  Transactions  of  the  Inter- 
national Congress  of  Psychiatry,  Neurology  and  Psychology, 
Amsterdam,  1907.  But  it  deserves  to  be  better  known,  for  as  an 
ideal  place  for  the  care  of  the  insane  it  is  unique,  there  being 
only  one  other  institution  for  the  insane  that  I  know  of  that  in 
anyway  embodies  what  should  be  our  own  ideal  as  far  as  con- 
cerns surroundings  and  construction,  and  that  is  the  Maison  de 
Falret  at  Vanves  in  the  outskirts  of  Paris. 

The  third  daughter  of  the  Emperor  Gosanjo  in  the  eleventh 
century  developed  melancholia  in  her  eighteenth  year.  Word 
was  brought  to  the  imperial  household  that  at  Iwakura  was  a 
holy  fountain  the  water  of  which  was  healing  to  mental  diseases 
and  to  disorders  of  the  eyes.  The  Emperor's  daughter  was  taken 
there  nearly  900  years  ago  and  recovered  and  so  brought  fame  to 
the  temple  and  the  well  of  Iwakura,  as  a  result  of  which  the  in- 
sane were  brought  there  in  great  numbers.  At  first  three  small 
inns  were  constructed  to  receive  them,  then  later  tea  houses  and 
villas  and  cottages  sprang  up  in  which  to  care  for  the  ever  in- 
creasing influx  of  patients. 


6  THE   INSANE    IN    JAPAN 

In  the  year  1889  the  village  had  239  houses,  with  1,579  in- 
habitants, and  up  to  that  year  one  to  two  patients  were  received 
into  each  family  to  share  in  the  occupations  of  the  household 
which  were  chiefly  out  of  door  employments  in  fields,  gardens 
and  forests. 

The  village  lies  at  the  foot  of  great  hills,  in  a  beautiful  wide 
valley.  The  hills  are  covered  with  evergreen  cryptomeria  pines 
and  spruces,  while  the  valley  is  cultivated  every  foot  of  it  with 
rice  and  vegetables.  Each  little  house  has  its  own  idyllic  charm. 
This  charm  lies  in  its  simplicity  of  architecture,  harmony  with 
the  landscape,  and  in  its  well-studied  gardens  both  inside  the 
court-yard  and  outside  around  the  house.  Paper  windows  and 
removable  paper  walls  insure  light  and  air  and  a  practical  out-of- 
door  life  night  and  day.  From  the  spotless  mats  upon  the 
floor  across  the  spotless  verandahs  one  looks  out  upon  the  gardens 
green  with  pines  and  cedars  all  the  year  round,  with  flowering 
shrubs  for  every  month  between  the  winters,  looks  out  into  the 
restful  gloom  of  the  giant  cryptomeria  woods  on  the  one  side,  or 
across  the  valley  of  rice-fields  to  the  evergreen  hills  upon  the 
other.  There  are  beautiful  paths  and  roads  among  these  cedar 
forests,  and  several  imposing  temples  among  them. 

In  1889,  the  Japanese  government,  evidently  under  the  im- 
pression gained  from  a  study  of  the  asylum  systems  of  Europe 
and  America  came  to  the  conclusion  that  their  colony  system  that 
had  grown  up  so  naturally  was  too  far  from  our  western  ideals, 
as  exemplified  in  our  colossal  caravanseries  for  the  insane,  and 
so  forbade  the  insane  being  any  longer  taken  to  the  village  of 
Iwakura.  They  abolished  the  method  as  probably  barbarous,  just 
as  at  one  time  they  abolished  cremation,  having  been  persuaded 
by  Europeans  that  it  was  heathen  practice,  but  returned  to  it  again 
when  they  learned  that  cremation  was  the  goal  to  which  western 
civilizations  are  tending  in  the  method  of  disposal  of  the  dead. 

The  result  of  this  opposition  of  the  government  has  been  to 
reduce  at  least  temporarily  the  number  of  insane  in  the  colony. 
It  is  altogether  likely  that  as  soon  as  the  authorities  learn  that  out 
of  themselves  they  have  developed  through  nearly  a  thousand 
years  the  best  of  all  methods  of  caring  for  the  insane,  toward 
which  the  West  itself  is  struggling  with  much  difficulty,  they 
will  remove  the  proscription  and  restore  Iwakura  to  its  ancient 


THE   INSANE    IN    JAPAN  7 

rights  and  privileges  under  state  organization  and  inspection. 
There  is  one  retreat  for  about  90  patients  at  Iwakura  built  on 
European  models  under  the  care  of  physicians,  to  which  excit- 
able cases  may  be  brought  from  the  family  homes  in  the  neigh- 
borhood. 

I  have  already  referred  casually  to  the  Maison  de  Falret,  a 
French  asylum  in  the  suburbs  of  Paris,  and  in  connection  with 
the  results  of  my  visit  to  Japanese  institutions  I  cannot  forbear  to 
mention  it  again  and  to  say  a  few  words  about  a  place  that  is 
probably  unknown  to  most  of  my  hearers,  because  after  all  the 
chief  value  of  any  observations  by  a  traveller  must  be  the  new 
knowledge,  the  example,  the  lesson  or  the  moral  that  he  brings 
home  to  his  own  people.  Doctors  Voisin  and  Falret  two  special- 
ists in  psychiatry  nearly  one  hundred  years  ago,  purchased  an 
estate  of  over  sixty  acres  in  the  environs  of  Paris,  made  of  it  a 
park,  and  planted  it  well  with  trees  and  shrubs.  A  pretty  stream 
courses  through  it.  They  built  therein  small  houses  or  bunga- 
lows, each  surrounded  with  high  green  hedges  and  pretty  gar- 
dens with  its  own  gateway.  Now  after  a  hundred  years  it 
realizes  their  dream  of  what  should  be  done  for  the  insane.  It  is 
a  large  park  with  magnificent  trees  and  shrubbery,  divided  into  two 
halves  by  a  farmstead  group,  thus  making  practically  two  parks, 
one  for  each  sex,  and  there  are  twenty-seven  such  bungalows 
for  the  isolation  of  one  or  more  patients.  A  patient  here  is  not 
only  isolated  from  his  friends,  which  is  usually  a  distinct  advan- 
tage, but  is  isolated  from  the  insane,  which  is  an  even  greater 
gain.  I  cannot  take  time  to  describe  it  here,  but  it  shares  with 
Iwakura  in  Japan  the  distinction  of  being  an  ideal  retreat  from 
the  standpoint  of  environment  and  construction  for  mental  cases. 

We  find  then  in  Japan  and  in  France  a  certain  standard 
already  attained  and  realized,  which  we  might  take  for  our  own. 
These  two  places  leave  nothing  to  be  desired  in  the  way  of 
surroundings  and  method  of  construction.  We  should  perhaps 
be  able  to  add  something  of  our  modern  machinery  to  these 
plans,  in  the  way  of  central  heating,  organization  of  food  supply 
and  service,  telephonic  intercommunication,  and  latter  day  hydro- 
therapy, but  these  are  not  the  essentials.  The  essentials  for  the 
care  of  the  curable  insane  are  already  here,  and  these  are  ade- 
quate nursing,  segregation,  the  return  to  nature,  the  simple  life, 


8  THE   INSANE   IN    JAPAN 

beautiful  surroundings,  association  with  normal  and  not  insane 
persons,  and  plenty  of  space  and  opportunity  for  walks,  for 
working  in  gardens  and  fields  and  at  various  arts  and  crafts. 

Have  we  already  drifted  too  far  from  the  realization  of  Vanves 
and  Iwakura,  with  our  vast  aggregations  of  3,000  to  5,000  patients 
in  one  institution,  with  the  sinking  of  the  individual  in  the  mass, 
with  our  appalling  overcrowding,  with  our  inferior  nursing  staff 
and  insufficient  medical  staff,  with  our  at  best  rudimentary 
methods  of  occupation,  and  with  our  immense,  expensive  and 
complicated  machinery  of  mere  support  and  custody? 


A  STUDY  IN  RACE   PSYCHOPATHOLOGY 
By  George  H.  Kirby,  M.D, 

DIRECTOR    OF    CLINICAL    PSYCHIATRY,     MANHATTAN     STATE    HOSPITAL, 

ward's   island,   N.   Y. 

Studies  in  psychopathology  which  seek  to  analyze  and  compare 
the  abnormal  mental  states  found  in  the  different  branches  of  the 
human  race  touch  a  number  of  highly  interesting  topics  and  have 
an  important  bearing,  not  only  on  the  special  problems  of  psy- 
chiatry and  mental  hygiene,  but  they  also  promise  to  furnish 
valuable  data  for  educators  and  social  workers. 

Just  as  we  see  racial  traits  and  peculiarities  of  a  people  finding 
expression  in  their  normal  mental  activities,  in  their  religion, 
morals,  politics  and  artistic  productions,  so  we  may  expect  to  dis- 
cover that  racial  characteristics  are  imparted  to  the  abnormal 
mental  life,  modifying  or  coloring  the  clinical  forms  of  those  psy- 
choses common  to  the  different  ethnological  groups  of  mankind.^ 
But  our  inquiry  leads  us  further  than  the  study  of  how  the  form 
and  symptoms  of  a  psychosis  may  vary  in  different  races ;  the 
deeper  and  more  important  question  of  etiology  becomes  the  prin- 
cipal consideration  when  it  is  shown  that  one  race  is  more  liable 
than  another  to  suffer  from  a  certain  kind  of  mental  disease.  The 
cause  for  this  susceptibility  of  one  race  and  relative  immunity  of 
another  can  only  be  explained  fully  when  a  whole  series  of  com- 
plex factors  has  been  analyzed. 

In  the  large  group  of  mental  disorders  dependent  on  exogenous 
causes,  such  as  syphilis,  alcohol,  infectious  diseases  or  other  phys- 
ical disturbances,  we  see  clearly  the  important  role  played  in  the 
genesis  of  these  psychoses  by  the  sexual  life,  social  customs,  occu- 
pations and  habits  of  the  race. 

In  the  other  large  group  of  mental  disorders,  the  so-called  func- 
tional psychoses,  endogenous  etiological  factors  seem  to  play  the 

*  See  an  interesting  report  by  Professor  Kraepelin  on  the  Mental  Dis- 
orders of  the  Natives  of  the  Island  of  Java.  Centralblatt  fur  Nerven- 
heilkunde  und  Psychiatric,  Vol.  15,   1904,  p.  433. 

9 


lO  A   STUDY    IN    RACE   PSYCHOPATHOLOGY 

most  important  role  and  among  these  are  to  be  mentioned  in  the 
first  place  certain  general  tendencies  of  the  personality,  analysis 
of  which  allows  us  to  differentiate  several  types  of  mental  makeup. 
My  interest  in  this  investigation  was  first  awakened  by  Meyer's 
description  of  the  various  types  of  personality  and  constitution, 
and  their  meaning  for  psychiatry.^  Interest  was  further  stimu- 
lated by  Hoch's  recent  communication  on  types  of  mental  makeup 
and  their  relation  to  the  functional  psychoses.  In  the  light  of 
these  studies  the  subject  of  race  psychopathology  becomes  espe- 
cially important.  If  groups  of  individuals,  because  of  a  peculiar 
kind  of  mental  makeup,  are  prone  to  develop  a  certain  form  of 
psychosis,  then  in  the  larger  racial  divisions  which  present  such 
distinctive  types  of  character  and  personality,  we  may  also  expect 
to  find  that  certain  forms  of  mental  disturbance  predominate  in 
the  one  or  the  other  race.  To  understand  this  racial  tendency 
through  analysis  of  the  factors  operative  in  the  inner  mental  life 
of  a  people  would  mean  to  make  an  important  addition  to  our 
knowledge  of  the  development  of  the  functional  psychoses. 

Most  of  the  studies  hitherto  made  in  comparative  psychiatry 
are  of  little  value.  This  is  the  natural  result  of  the  lack  of  uni- 
formity in  the  clinical  conceptions  of  different  observers,  together 
with  the  confusion  in  nomenclature.  It  is,  therefore,  to-day 
utterly  useless  to  attempt  to  use  the  hospital  reports  of  different 
countries  in  order  to  estimate  the  frequency  with  which  any  par- 
ticular mental  disorder  occurs  in  the  various  races,  or  to  learn 
what  deviations,  if  any,  exist  in  the  clinical  forms  of  the  psychoses 
occurring  among  the  different  peoples  of  the  world.  For  investi- 
gations in  this  field  to  be  of  any  value,  it  would  seem  essential,  as 
pointed  out  by  Kraepelin,  that  the  studies  be  carried  out  by  the 
one  observer ;  otherwise,  no  comparable  data  are  to  be  expected. 
This  requirement  is  readily  met  at  the  Manhattan  State  Hospital 
where  the  clinical  material  offers  a  rare  opportunity  for  research 
in  comparative  psychiatry.  In  New  York  city  the  conditions  of 
a  nice  experiment  are  practically  fulfilled  in  that  a  number  of 
races  of  pure  blood  are  found  living  in  large  colonies  in  a  uniform 
general  environment.  The  outcome  of  such  a  situation  must  be 
full  of  interest  to  the  psychopathologist. 

'An  Attempt  at  Analysis  of  the  Neurotic  Constitution.  Adolf  Meyer, 
American  Journal  of  Psychology,  Vol.  XIV,  p.  90,  July-September,  1903. 


A    STUDY    IN    RACE   PSYCHOPATHOLOGY 


II 


In  this  preliminary  report  I  wish  to  present  merely  the  result 
of  a  review  of  the  clinical  material  of  the  past  year^  made  to 
ascertain  the  relative  frequency  of  the  different  psychoses  in  the 
various  races  entering  the  hospital.  Among  the  admissions  during 
the  year  were  found  representatives  of  twenty-seven  different 
racial  groups.  In  seven  of  these  groups  the  number  of  cases 
seems  sufficiently  large  to  allow  certain  comparisons.  Our  attempt 
has  been  made  to  compare  in  the  first  place  racial  stocks,  without 
regard  to  nationality  or  geographical  distribution.  Under  the 
Irish,  for  instance,  we  include  native-born  Irish  and  the  first 
generation  of  children  born  in  America  of  native  Irish  parents. 
In  a  similar  way  the  German,  Italian  and  English  groups  are 
formed.  We  have  restricted  the  American  group  so  as  to  com- 
prise only  those  indivdiuals  whose  parents  were  born  in  the  United 
States,  but  this  does  not  include  the  Negroes  and  Jews,  who  are 
kept  apart  and  form  each  a  group  without  regard  to  country  of 
birth  or  length  of  time  in  America. 


Psychosis. 


Psychoses  with  organic  nervous 
disease  , 

Senile  psychoses  

General  paralyses , 

Alcohol  ic  psychoses 

Infective-exhaustive 

Involution  melancholia 

Depressions  undifferentiated 

Dementia  praecox 

Paranoic  conditions 

Manic-depressive 

Epileptic  psychoses 

Constitutional  inferiority  and 
psycho-neuroses 

Idiocy  and  imbecility  

Unclassified 


Total  number  persons  each  race 


. 

.  c 

js  a 

ja  V 

ui    U 

.2  0 

■?u 

2.69 

0.98 

9.80 

2.87 

7..S9 

14.05 

27.69 

0.32 

5.39 

4.47 

1.71 

3.19 

1.96 

5. 43 

I3.4« 

27.47 

S-M 

I.S9 

16.66 

28.43 

2.20 

1.59 

2.94 

6.07 

0.24 

0.98 

2-45 

2.5s 

408 

313 

su 


I-"    V 


1-54 
6.70 
20.10 
11.85 
8.64 
2.06 

5.15 
14.95 

8.25 
12.89 

4.64 

4.64 

0.51 
2.06 


194 


2.38 

7.14 

17.46 

11.90 

4.76 

1.58 

1.58 

16.66 

7.92 
18.25 

3.17 

3.96 
0.79 
2.38 


126 


1h            ^ 

0  0 

p:s 

-a  c 

•5  S  S 

=  U 

boCJ 

T.*-^ 

OS^ 

2  I- 

=  (3b 

1.96 

2.85 

1.53 

3.70 

9.80 

5-71 

5.64 

9.87 

29.41 

14.28 

10.25 

8.64 

7.82 

11.42 

7.69 

8.64 

5.88 

— 

6.66 

1.23 

2.8s 

1.53 

8.64 

3.92 

— 

9.22 

23.44 

13.72 

28.57 

29.23 

7.40 

5.88 

8.57 

5.12 

13.58 

9.80 

17.14 

13.33 

4.93 

3.92 

2.85 

1.02 

2.46 

1.96 

5-71 

2.56 

1.23 

— 

— 

— 

6.17 

5.88 

— 

6.15 

81 

51 

35 

195 

25 

92 

184 

182 

74 
28 

64 
284 

74 

253 

36 

53 

7 

45 

1403 


The  accompanying  table  shows  the  results  of  the  analysis.  The 
total  number  of  patients  included  in  the  study  was  1,403.  The 
bottom  row  of  figures  shows  the  number  of  each  racial  type 
admitted  to  the  hospital,  the  Irish  with  408  persons  forming  the 

■  Cases  admitted  from  October  i,  1907,  to  September  30,  1908. 


12  A   STUDY   IN    RACE   PSYCHOPATHOLOGY 

largest  group,  the  English  with  35  persons  forming  the  smallest. 
The  vertical  columns  show  the  percentage  distribution  of  the  vari- 
ous psychoses  within  each  racial  group. 

Irish  stock  furnished  nearly  30  per  cent,  of  all  the  admissions. 
The  figures  for  this  race  demonstrate  in  a  most  convincing  manner 
the  important  role  played  by  alcohol  in  the  mental  disturbances  of 
the  Irish  people.  Twenty-seven  per  cent,  of  all  the  Irish  admitted 
were  suffering  from  alcoholic  insanity,  the  proportion  being  more 
than  double  that  found  in  any  other  race.  Within  the  alcoholic 
group  itself  the  Irish  contributed  62  per  cent,  of  all  the  cases  (113 
out  of  182  cases  of  alcoholic  insanity).  Accompanying  this  extra- 
ordinarily large  percentage  of  alcoholic  disorders  we  find  further 
that  the  Irish  stand  highest  in  senile  dementia  and  psychoses 
accompanying  organic  nervous  diseases.  In  general  paralysis,  on 
the  other  hand,  the  percentage  is  lower  than  in  any  other  race. 
This  latter  finding  was  rather  a  surprise.  It  is  an  interesting  fact 
taken  in  connection  with  the  view  often  expressed,  that  alcohol 
plays  an  important  role  in  conjunction  with  syphilis  in  the  causa- 
tion of  general  paralysis.  Our  figures  for  the  Irish  race  tend  to 
show  a  closer  relationship  between  alcoholism,  senile  dementia 
and  various  organic  brain  diseases  than  between  alcoholism  and 
the  meta-syphilitic  disorders,  such  as  general  paralysis. 

The  figures  for  the  Jewish  race  bring  out  several  interesting 
facts.  One  notices  first  of  all  that  the  Hebrews  are  practically 
free  from  alcoholic  psychoses.  The  figure  .32  per  cent,  represents 
a  single  case  which  occurred  in  a  series  of  182  cases  of  alcoholic 
insanity.  I  must  also  add  that  this  particular  patient,  a  man,  is 
still  under  observation,  having  been  over  a  year  in  the  hospital 
and  certain  features  in  the  development  of  the  psychosis  as  well 
as  the  course  of  the  disorder  suggest  the  possibility  that  the  case 
may  after  all  belong  with  the  paranoid  dementias.  We  notice  the 
further  interesting  fact  that  the  absence  of  alcoholic  insanity  in 
the  Hebrew  is  accompanied  by  the  lowest  figure  for  senile 
dementia  and  psychoses  with  organic  nervous  diseases.  The  next 
most  noteworthy  fact  gathered  from  the  second  column  is  that  the 
Hebrew  race  shows  by  far  the  greatest  percent-age  of  manic- 
depressive  cases  (28.43  per  cent.)  and  the  Jew  also  stands  highest 
in  the  psycho-neuroses  and  constitutional  inferiorities  and  in  invo- 
lution melancholia.     In  dementia  prsecox,  with  the  exception  of 


A    STUDY   IN    RACE   PSYCHOPATHOLOGY  I  3 

the  English  people  (28.57  P^r  cent.),  the  Hebrews  are  again  fore- 
most (27.47  per  cent.).  In  the  undifferentiated  depressions  they 
are  next  to  the  highest.  We  thus  see  that  in  the  large  group  of 
the  so-called  functional  psychoses,  by  which  we  mean  those  dis- 
orders in  which  certain  endogenous  or  psycho-genetic  factors  seem 
most  important  as  upsetting  causes,  the  Jewish  people  outnumber 
enormously  any  other  race. 

Among  the  Germans  general  paralysis  ranks  high  (20.10  per 
cent.),  a  higher  percentage  being  reached  only  in  the  Negro  (29.41 
percent.).  Mental  disturbances  of  alcoholic  origin  are  also  rather 
frequent  in  the  Germans,  and  one  observes  a  striking  uniformity 
in  the  figure  for  the  Anglo-Germanic  group — the  German,  Amer- 
ican and  English  groups  each  showing  11  per  cent,  of  alcoholic 
psychoses.  We  notice  further  that  the  Germans  are  also  rela- 
tively high  in  senile  psychoses,  infective-exhaustive  states,  para- 
noic conditions,  and  the  psycho-neuroses  and  constitutional  infe- 
riorities. In  the  manic-depressive  group  the  Germans  rank  low 
(12.89  P^r  cent.),  the  only  lower  figure  being  found  among  the 
Negroes  (9.80  per  cent.). 

The  figures  for  descendants  of  native  born  Americans  are  given 
in  the  fourth  column.  The  percentages  in  this  group  seem  to 
occupy  somewhat  of  an  intermediate  position  between  those  of  the 
other  races,  that  is  to  say  there  are  no  extraordinarily  high  or  any 
strikingly  low  figures  in  the  American  group.  Manic-depressive 
insanity  is,  however,  rather  high,  a  higher  percentage  being  found 
only  in  the  Hebrew ;  in  alcoholic  psychoses  and  general  paralysis 
a  relatively  high  figure  is  reached  by  the  native  Americans. 

In  the  remaining  three  races — Italian,  Negro  and  English — the 
number  of  cases  is  smaller  than  in  the  preceding  groups  and  the 
percentages  are  therefore  probably  less  representative  for  these 
races. 

In  the  Italian  group  we  find  that  general  paralysis  and  alcoholic 
psychosis  are  both  strikingly  low.  The  undifferentiated  depres- 
sions and  dementia  prsecox  are  high.  Epileptic  disorders  are  more 
frequent  than  in  any  other  race  {4.93  per  cent.).  We  see  further 
that  the  unclassified  group  shows  a  high  figure  which  may  mean 
that  the  Italian  people  offer  a  larger  number  of  atypical  or  obscure 
disorders  than  other  races.     It  may  be,  however,  that  inaccessi- 


14  A   STUDY    IN    RACE   PSYCHOPATHOLOGY 

bility  because  of  the  language  difficulty  is  partly  responsible  for 
this  high  figure. 

In  the  black  race  we  meet  with  a  remarkably  high  percentage  of 
general  paralysis  (29.41  per  cent.),  higher  by  far  than  that  found 
in  any  other  race.  This  figure  may  surprise  one  in  view  of  claims 
not  long  since  made  that  the  Negroes  were  almost  entirely  free 
from  meta-syphilitic  disorders,  not  only  general  paralysis  but  also 
tabes.  The  proportion  of  women  among  the  Negro  general  para- 
lytics seems  to  be  unusually  high.  The  average  of  all  races  exclu- 
sive of  the  Negro  was  not  quite  4  men  to  i  woman.  In  the 
Negroes  we  find  the  proportion  to  be  3  men  to  2  women.  The 
alcoholic  disorders  are  lower  in  the  Negro  than  in  any  other  race 
except  the  Hebrew.  This  low  proportion  of  alcoholic  insanity 
was  hardly  expected,  as  the  Negro  has  been  described  as  being 
especially  sensitive  to  toxic  influences.  Manic-depressive  insanity 
seems  to  be  infrequent  in  the  Negro,  the  percentage  (9.80)  being 
in  fact  lower  than  that  found  in  any  other  race. 

Among  the  English  patients,  of  whom  there  were  only  a  small 
number  admitted,  35  altogether,  we  find  that  dementia  praecox 
is  proportionately  more  frequent  than  in  any  other  race  (28.57  V^^ 
cent.),  the  figure  being,  however,  only  slightly  higher  than  that 
found  in  the  Hebrew  (27.47  per  cent.). 

The  more  important  results  of  the  study  may  he  summarized 
as  follows: 

The  Irish  are  clearly  more  prone  to  develop  alcoholic  disorders 
than  any  other  one  of  the  races  considered.  They  are  also  more 
liable  to  senile  deterioration  and  other  psychoses  with  organic 
brain  disease. 

The  Jewish  race  seems  practically  free  from  alcoholic  insanity. 
The  Hebrew,  however,  ranks  higher  by  far  than  any  other  race 
in  the  functional  group  of  psychoses  made  up  of  manic-depressive 
insanity,  dementia  praecox,  constitutional  disorders  and  depres- 
sions of  various  form. 

In  the  Negro  general  paralysis  occurs  proportionately  with 
more  frequency  than  in  any  other  race.  Alcoholic  disorders  re- 
main at  a  low  figure.  In  the  functional  psychoses,  particularly 
manic-depressive,  the  Negro  ranks  low. 

The  Germans  are  relatively  high  in  general  paralysis. 

The  Italians  are  low  in  both  general  paralysis  and  alcoholic 


A   STUDY    IN    RACE    PSYCHOPATHOLOGY  1 5 

insanity.  They  are  highest  in  epileptic  disorders  and  furnish  the 
largest  percentage  of  unclassified  cases. 

The  English  are  highest  in  dementia  prsecox  but  the  small  num- 
ber of  English  people  included  in  the  study  renders  this  figure 
rather  unreliable. 

The  American  group  shows  no  striking  figures  when  compared 
with  other  races,  but  manic-depressive  insanity,  general  paralysis 
and  alcoholic  disorders  reach  a  relatively  high  percentage  in  people 
whose  parents  were  born  in  the  United  States. 


THE   CURABILITY  OF  EARLY   PARESIS 

By  Charles  L.  Dana 

professor  of  nervous  diseases,  cornell  university  medical  college,  n.  y. 

Introductory 

In  Professor  Tanzi's  recent  work  on  Mental  Diseases,  discuss- 
ing progressive  paralysis,  he  states  that  the  disease  may  be  unrec- 
ognized for  years  and  that  the  actual  duration  of  paresis  may  be 
ten  or  fifteen  years — in  fact  may  last  as  long  as  do  cases  of  tabes. 

With  regard  to  the  prognosis,  he  says : 

"Although  it  is  dogmatically  stated  that  progressive  paralysis 
is  essentially  an  incurable  and  fatal  disease,  we  can  not  entirely 
exclude  that  if  it  is  promptly  diagnosed  and  energetically  treated, 
the  morbid  process  may  be  arrested.  Moreover,  the  essentially 
initial  lesions  of  progressive  paralysis  (chromatolysis  of  nerve 
cells,  tumefaction  of  cell  body)  are  not  of  a  destructive  character, 
nor  are  they  altogether  irreparable"  (Tanzi,  Mental  Diseases, 
1909,  p.  419). 

Dr.  Gilbert  Ballet  recently  reported  a  case  (Societe  de  Psychia- 
trie,  L'Encephale,  February  10,  191 1)  of  a  patient  who  in  1902 
or  1903  presented  very  marked  delusions  of  grandeur  with  symp- 
toms of  tabes.  The  patient  recovered  from  his  mental  disturb- 
ance and  is  now  well.  Ballet  considered  him  to  belong  to  a  group 
of  cases  to  which  he  has  called  attention,  of  general  paralysis  with 
possible  arrested  evolution,  "  paralysis  generale  a  evolution  dis- 
continue." 

These  are  practically  the  views  for  which  I  have  contended  in 
the  papers,  the  first  being  published  seven  years  ago :  viz.  that 
so-called  luetic  neurasthenia,  luetic  melancholia  and  luetic  pseudo- 
paresis  are  often  if  not  always,  preliminary  and  preparatory  stages 
of  paresis.  If  energetically  treated,  the  patient  is  cured  or  re- 
lieved, if  not  treated,  the  malady  usually  goes  on  into  the  degen- 
erative  and    incurable    stage.      It   occasionally   happens    that   a 

3  17 


1 8  THE    CURABILITY   OF    EARLY    PARESIS 

periodic  functional  psychosis  (mania  or  melancholia)  may  be 
grafted  upon  a  nervous  lues. 

The  view  that  cerebral  lues  is  one  disease  and  paresis  quite 
another  is  too  narrow  a  one  to  hold  in  the  light  of  recent  observa- 
tions. 

In  an  inflammatory  process  we  do  not  call  the  initial  con- 
gestion and  exudation  one  disease,  the  terminal  cell  degeneration 
and  necrosis  another,  though  one  is  curable,  the  other  is  not.  So 
it  seems  to  me  that  a  cerebral  lues  with  neurasthenic  and  mild 
paretic  symptoms  represent  the  beginning  yet  curable  phase  of  a 
process  that  naturally  and  untreated  ends  in  a  hopeless  degen- 
eration. 

Some  interesting  facts  regarding  the  essential  unity  of  the 
processes  have  been  furnished  by  the  newer  methods  of  studying 
the  blood  and  cerebrospinal  fluids. 

So  far,  the  laboratory  observations  have  not  furnished  any  sure 
criterion  by  which  we  can  say  that  a  case  is  nervous  lues,  or  is 
paresis.  In  each  condition,  there  is  an  increase  of  cells  in  the 
cerebrospinal  fluid,  though  less  in  paresis  than  in  exudative  syph- 
ilis of  the  brain ;  in  each  the  blood  and  cerebrospinal  Wassermann 
tests  and  the  globulin  tests  are  positive, — more  intensely  so  in 
paresis,  as  a  rule. 

Dr.  Kaplan  has  shown  that  under  mercurial  treatment  the  reac- 
tions of  the  cerebrospinal  fluid  in  tabes,  paresis  and  cerebrospinal 
lues  respond  in  the  same  way.  In  all  three  of  these  conditions 
there  are  found  before  treatment : 

Lymphocytosis  4- 
Globulin  test  -}- 
Blood-Wassermann  + 
Cerebrospinal  Wassermann  + 
Fehling's  reaction  o 

Under  treatment,  there  comes  usually  earliest  a  reduction  in  the 
number  of  cells ;  then  the  globulin  reaction  becomes  negative,  then 
the  blood-Wassermann  and  finally  the  cerebrospinal  Wassermann 
tests  also  become  negative.  As  the  lymphocytosis  diminishes  the 
Fehling  reaction  returns.  These  reactions  suggest  that  we  are 
attacking  the  same  conditions ;  and  not  as  I  believe  three  different 
diseases. 


THE    CURABILITY   OF   EARLY    PARESIS  1 9 

So  far  as  investigations  yet  have  gone,  then,  it  seems  rather 
plain  that  paresis  is  not  a  disease  sharply  split  off  from  cerebral 
lues  but  rather  a  later  phase  of  it.  The  exact  line  can  not  yet 
be  drawn,  but  I  contend  that  there  is  often  a  long  period  of  time 
during  which  symptoms  occur  that  are  "  pre-paretic,"  and  that 
this  condition  should  be  recognized  since  it  is  curable,  in  the  sense 
that  it  is  kept  as  permanently  under  control  as  lues  itself  can 
be  kept. 

The  phases  in  which  pre-paresis  shows  itself  most  commonly 
are:  (i)  Luetic  neurasthenia,  (2)  luetic  neurasthenia  with  paretic 
symptoms  (pseudo-paresis)  (meningeal  and  cortical  lues),  (3) 
luetic  melancholia  and  mania. 

The  forms  of  cerebral  and  spinal  lues  with  local  exudates,  gum- 
mata,  etc.,  may  or  may  not  be  associated  with  or  become  pre- 
cursors of  paresis. 

My  experience  teaches  me  that  spinal  exudative  syphilis  (in 
the  common  form  of  Erb's  paralysis)  is  rarely  followed  by 
cerebral  but  often  by  spinal  degenerations;  cerebral  syphilis  with 
exudates  are  not  ominous  if  they  involve  the  brain  stem;  but 
the  diffuse  meningeal  lues  involving  probably  the  cerebral  cor- 
tex causes  symptoms  resembling  paresis  and  leads  directly  to 
it  unless  treated.  In  this  condition  the  symptoms  sometimes  can 
not  be  distinguished  from  the  symptoms  of  paresis;  and  if  neg- 
lected the  evidences  of  degeneration  in  time  almost  invariably 
appear. 

FIRST  PAPER,   READ   NOVEMBER,    I904 

I  wish  to  present  what  to  my  mind  is  convincing  evidence  that 
paresis,  in  its  very  earliest  stages,  in  that  stage  which  may  be 
called  one  of  "  preparesis,"  is  a  disease  that  sometimes  can  be 
arrested.  This  arrest  may  be  permanent,  and  may  be  attended 
with  so  little  mental  defect  that  one  may  call  the  patient  practi- 
cally cured. 

Paresis,  Tabes  and  Syphilis. — It  is  now  quite  generally  admitted 
that  paresis  is  almost  always  a  parasyphilitic  disease  ;  that  is  to  say, 
one  which  is  due  to  the  late  and  degenerative  influence  of  a  luetic 
poison.  Paresis  is  also  looked  on  as  a  disease  which  has  the  same 
relation  to  the  brain  structures  that  tabes  dorsalis  has  to  those  of 
the  spinal  cord. 


20  THE    CURABILITY   OF   EARLY   PARESIS 

This  relationship,  indeed,  is  so  often  and  so  plainly  observed 
that  it  can  be  considered  a  proved  clinical  and  pathologic  fact. 
We  find  for  example,  in  from  5  to  10  per  cent,  of  the  cases  of 
degenerative  syphilis  of  the  nervous  centers  that  the  patient 
suffers  both  from  paresis  and  from  tabes,  and  has  what  is  termed 
"  tabo-paresis,"  the  paresis  gradually  associating  itself  with  tabes, 
or  vice  versa. 

The  Arrest  of  Tabes. — Now,  nothing  is  more  clearly  established 
than  the  fact  that  tabes  dorsalis  is  often  arrested  in  its  early 
stages,  so  that  a  patient  may  live  for  ten,  twenty  or  thirty  years, 
and  exhibit  no  practical  progress  or  change  in  his  symptoms.  I 
have  a  number  of  patients  under  observation  who  illustrate  this 
undoubted  condition;  and  my  experience,  I  am  assured,  is  the 
common  one. 

If,  then,  tabes  may  be  arrested  in  its  early  or  pretabetic  stage, 
there  seems  no  reason  to  suppose  that  we  can  not  also  arrest  and 
cure  paresis  in  its  earlier  stage,  and  this  is  what  I  believe  can 
be  done. 

The  cases  which  I  report,  taken  in  connection  with  other  clinical 
experiences  which  it  is  impossible  to  present  without  making  my 
paper  too  long,  have  been  sufficient  to  make  me  feel  quite  sure  of 
my  position  in  the  matter.  I  am  not  asserting  that  paresis,  when 
it  is  once  well  established,  can  be  cured.  In  fact,  I  do  not  think 
it  can  be ;  and  I  know  of  no  more  hopeless  malady  when  it  has 
once  got  a  full  start. 

Paresis  not  infrequently  shows  remissions,  and  these  remissions 
may  be  prolonged  to  one  or  two,  or  even  to  five  or  six  years.  In 
these  remissions,  however,  the  mind,  by  no  means,  is  restored  to 
its  original  tone  or  vigor.  The  patient  has  only  a  "let-up,"  and 
is  never  the  sound,  vigorous-minded  man  he  was  previously.  My 
patients  have  been  more  than  cases  of  remission ;  their  condition 
of  mind  and  body  has  been  restored,  practically,  to  a  normal  level. 
I  am  not  asserting  the  existence  of  remissions  in  paresis ;  that  is 
one  of  the  admitted  features  in  the  natural  history  of  the  disease. 
What  I  do  assert  is  that  in  some  cases  in  which  the  patient  has 
shown  unmistakable  evidences  of  a  degenerative  and  paretic 
process  starting  in  the  brain,  this  process  has  been  arrested,  evi- 
dences of  it  have  even  sometimes  entirely  disappeared,  and  the 
patient  has  gone  on  with  his  usual  work. 


THE   CURABILITY   OF   EARLY    PARESIS  21 

I  have  not  yet  had  patients  under  observation  for  a  sufficiently 
long  period  of  years  to  enable  me  to  say  that  the  paresis  will  never 
return.  I  can  only  argue  from  analogy  in  the  cases  of  tabes  dor- 
salis,  and  since  we  know  that  here  the  arrest  of  progress  is  some- 
times permanent,  we  may  legitimately  infer  that  when  it  has 
occurred  in  paresis  in  the  same  way  it  may  also  be  permanent. 
I  would  say,  further,  that  there  is  nothing  a  priori  impossible  in 
the  idea  that  paresis  may  be  arrested  and  cured  when  it  first  starts 
in.  We  are  able  to  arrest  degenerative  processes  in  other  parts 
of  the  nervous  system;  we  arrest  degenerative  processes,  or  we 
see  them  arrested,  in  the  kidneys,  in  the  liver  and  in  other  organs. 
Given  a  vigorous  constitution  poisoned  with  disease,  it  may  well 
be  that  when  it  is  put  under  the  best  possible  conditions  for  fight- 
ing this  poison,  when  its  known  antidote  has  been  administered 
with  heroic  thoroughness,  we  might  expect  that  the  tendency  of 
the  tissue  to  die  may  cease. 

Pseudoparesis. — Also,  in  speaking  of  paresis,  I  wish  to  be 
understood  that  I  am  speaking  only  of  general  paresis  or  paralytic 
dementia,  not  of  the  so-called  "  pseudoparesis  "  of  alcoholics  or 
the  "pseudoparesis"  of  syphilis.  I  have  used  these  terms  per- 
sonally, and  I  know  they  are  widely  adopted  as  convenient  expres- 
sions. I  do  not  think,  however,  that  this  term,  "  pseudoparesis  " 
is  a  very  fortunate  one,  inasmuch  as  the  disorders  above  men- 
tioned are  essentially  simple  forms  of  organic  dementia,  with  an 
entirely  different  pathologic  basis  and  clinical  course  from  the  real 
paresis.  The  so-called  pseudoparesis  of  alcoholism,  for  example, 
is  only  an  organic  dementia,  due  to  the  connective  tissue  prolifera- 
tion, the  vascular  changes,  and  the  cellular  atrophy  brought  on 
by  the  continued  use  of  alcohol.  The  pseudoparesis  of  syphilis  is 
simply  a  dementia  brought  on  by  the  exudates  of  syphilis,  leading 
to  more  or  less  severe  secondary  changes  in  the  meninges  and  in 
the  vascular  supply.  It  is  really  an  organic  dementia,  due  to  an 
exudative  inflammation  of  the  meninges  and  blood  vessels.  In 
true  paresis  the  organic  changes  are  comparatively  slight  at  the 
beginning,  and  are  probably  mostly  of  a  parenchymatous  nature. 
There  is  no  exudate  and  no  early  gross  organic  change.  It  is 
true,  however,  that  in  the  early  stages  of  paresis  there  may  be 
some  slight  amount  of  luetic  exudate,  and  that  perhaps  the  degen- 
erative changes  in  the  cell  are  started  by  this  process.     We  know 


22  THE    CURABILITY   OF   EARLY    PARESIS 

also  that  there  are  cases  of  paresis  in  which  there  are  both  true 
primary  degenerative  changes  and  real  syphilitic  exudates  present 
at  the  same  time,  so  that  the  patient  may  be  said  to  be  suffering 
both  from  brain  syphilis  and  from  a  paresis.  It  is  strictly  analo- 
gous to  the  conditions  which  occur  in  a  spinal  cord,  where  at 
times  there  may  be  a  true  tabetic  degeneration  and  at  the  same 
time  a  decided  syphilitic  exudate,  so  that  we  have  both  locomotor 
ataxia  and  spinal  syphilis  together. 

It  is  at  this  point  that  the  weakness  of  my  case,  as  I  freely 
admit,  may  lie.  It  may  be  and  probably  will  be  contended  that 
the  cases  which  I  assert  are  in  the  stage  of  "  preparesis  "  are  really 
cases  only  of  slight  exudative  brain  syphilis,  and  that  my  patients 
have  simply  been  cured  of  a  slight  degree  of  a  perhaps  rather 
diffuse  vascular  and  meningitic  exudate.  To  this  I  can  only 
reply  that  I  have  many  times  seen  precisely  this  class  of  cases 
passing  directly  into  a  condition  of  true  paresis,  and  that  in  all 
of  my  cases  where  there  were  admittedly  some  symptoms  of 
syphilitic  exudate,  or  some  kind  of  gross  organic  lesion,  there 
were  with  it  also  decided  psychical  and  somatic  symptoms,  such 
as  occur  only,  or  mainly,  in  connection  with  the  degenerative 
process  of  paresis.  An  Argyll-Robertson  pupil,  for  example,  is 
the  sign  of  the  onset  of  a  degeneration,  not  of  exudation.  At  the 
very  most,  while  admitting  that  my  opponents  may  be  academic- 
ally right,  I  would  claim  that  they  are  practically  wrong,  for  the 
reason  that,  basing  my  argument  on  experience  with  other  cases, 
I  feel  sure  that  all  or  nearly  all  of  these  patients  would  have  gone 
into  a  condition  of  true  paresis  if  they  had  been  let  alone.  Thus, 
when  a  patient  who  has  given  a  distinct  history  of  syphilis  develops 
a  form  of  agitated  melancholia,  and  at  the  same  time  shows  signs 
of  cerebral  degeneration,  like  the  Argyll-Robertson  pupil  and  dis- 
turbances in  the  knee  reflexes,  I  should  certainly  be  apprehensive 
that,  under  ordinary  conditions,  he  would  eventually  develop  a 
paresis,  for  I  have  seen  a  number  of  patients  who  entered  paresis 
through  this  peculiar  gate  of  melancholia,  with  somatic  signs  as 
indicated. 

Again,  if  a  patient  with  a  history  of  syphilis,  after  a  certain 
period  begins  to  develop  convulsions  and  shows  Argyll-Robertson 
pupils,  exaggerated  reflexes,  then  begins  to  develop  symptoms  of 
loss  of  memory,   change  of  character  and   disturbances  of   the 


THE    CURABILITY   OF   EARLY    PARESIS  23 

instinctive  feelings ;  I  should  feel  very  certain  that  if  left  alone 
he  would  pass  into  the  condition  of  paresis,  for  it  is  through  the 
gate  of  convulsivedisturbances,  epileptiform  seizures  and  peculiar 
somatic  signs  that  paresis  sometimes  develops. 

Still  further,  when  a  patient,  who  gives  perhaps  a  doubtful  his- 
tory of  syphilis  but  whose  life  is  such  that  he  might  easily  have 
been  subjected  to  it,  and  who  has  a  headache,  an  eye-palsy,  and 
previous  to  that  has  for  some  time  shown  great  extravagance  in 
action  and  ideas,  with  a  decided  change  in  character  and  weakness 
of  memory,  I  would  here  also  feel  very  sure  that  a  paresis  was 
developing. 

Having  observed  the  total  disappearance  of  all  these  symptoms, 
under  treatment,  and  the  restoration  of  the  patients  practically  to 
their  former  health,  it  has  seemed  to  me  that  I  may  be  right  in 
claiming  that  it  is  possible  to  arrest  for  an  indefinite  time  a  dis- 
ease which  is  certain  to  become  a  general  paresis. 

With  these  preliminary  remarks,  I  submit  the  following  rec- 
ords. They  are  not  published  in  every  detail  because  it  seemed 
to  me  not  necessary.  I  have  given  the  salient  facts  with  regard 
to  the  symptoms  and  course ;  besides  this,  the  patients  were  all 
private  patients  of  my  own  or  of  physicians  who  referred  the 
cases  to  me,  and  some  of  the  patients  were  men  of  prominence, 
whose  intimate  lives  and  identity  I  should  dislike  to  expose.  The 
histories  should  perhaps  carry  greater  weight  for  the  reason  that 
they  are  not  records  of  hospital  or  dispensary  cases,  in  which 
data  are  often  uncertain  and  the  mental  development  of  the  pa- 
tients of  mediocre  type: 

Case  Reports 

Case   i. — M.    S.,   aged  40,   married;   occupation,   broker. 

History. — Family  history  shows  a  very  bad  indirect  heredity.  The 
patient  had  an  infection  before  he  was  20,  which  was  treated.  He  had 
had  seven  healthy  children.  He  had  led  a  life  of  much  social  activity  and 
business  excitement.  Three  months  before  I  saw  him  he  began  to  get 
ideas  of  poverty  and  self-reproach,  and  when  I  saw  him  he  had  a  distinct 
melancholia. 

Examination. — The  pupils  were  unequal,  the  left  larger  than  the  right; 
both  distinctly  Argyll-Robertson  in  type,  though  the  right  reacted  very 
feebly  to  light.  He  claimed,  however,  that  the  left  pupil  had  been  larger 
than  the  right  for  fourteen  years,  and  that  this  condition  was  due  to  a 
sunstroke    (?).     The  left  knee  jerk  was  lively,  the  right  weak.     He  had 


24  THE    CURABILITY   OF   EARLY    PARESIS 

some  tremor  of  the  hands,  but  none  of  the  face.  There  was  no  speech 
disturbance.  He  had  had  no  seizures.  Mentally  he  showed  no  dementia, 
but  only  a  very  profound  and  anxious  depression,  with  some  delusions 
of  poverty  and  self-accusation.  He  suffered  from  insomnia,  but  had  no 
headaches,  and  had  no  cranial  nerve  palsies  except  those  of  the  eyes,  and 
no  disorders  of  the  spinal  centers  or  ataxia. 

Treatment  and  Result. — He  was  seen  by  two  physicians,  one  a  very 
competent  neurologist,  who  thought  that  he  was  developing  paresis.  He 
was  sent  to  a  sanitarium,  where  he  was  put  under  active  treatment.  In  six 
months  he  came  back  practically  well.  The  pupil  of  the  right  eye  had 
become  normal;  the  left  was  the  same  as  before;  knee  jerks  same  as 
before.  He  has  continuted  well  and  has  been  in  active  business  now  for 
over  three  years. 

Case  2. — J.  D.  H.,  aged  37,  married ;  merchant  by  occupation. 

Family  History. — Direct  heredity  good;  one  sister  had  epilepsy;  no 
other  neuroses  in  the  family. 

Personal  History. — He  had  a  luetic  infection  twelve  years  ago.  He 
was  a  man  of  temperate  habits,  but  worked  extremely  hard.  About  two 
years  before  I  saw  him  he  began  to  run  down  and  complained  of  sensa- 
tions of  pressure  on  the  side  of  his  head,  which  symptoms  continued  very 
persistently. 

Examination. — The  pains  and  paresthesias  extended  down  the  back  of 
the  neck  and  into  the  shoulders.  In  other  words,  he  had  the  annoying 
head,  neck  and  shoulder  paresthesias  seen  in  beginning  paresis.  As  his 
condition  grew  worse  he  began  to  be  drowsy,  and  apparently  required  more 
sleep  than  normal.  Three  weeks  before  I  saw  him  he  had  had  two  con- 
vulsions of  an  epileptiform  character.  At  that  time  he  was  emotional  and 
depressed,  crying  easily,  and  having  apprehensions  about  his  mind  giving 
way.  When  seen  by  me  he  had  been  taking  for  some  days  15  grains  of 
bromid  in  the  morning  and  6  grains  of  trional  at  night.  At  this  time 
he  was  depressed,  his  memory  was  poor,  his  spech  was  syllabic,  but  he 
had  no  tremor,  and  the  pupils  were  normal,  as  were  also  the  knee  jerks. 
He  was  then  having  attacks  of  excitement  at  intervals  with,  at  times,  some 
brief  delusions,  but  no  hallucinations.  He  complained  of  his  head  and 
was  very  depressed  and  apprehensive.  He  appeared  to  me  to  have  the 
physiognomy  of  a  patient  likely  to  develop  paresis,  and  the  history  of 
convulsions,  his  speech  disturbance,  his  feeble  memory  and  his  melan- 
cholia, all  pointed  in  that  direction.  At  the  time  I  made  a  diagnosis  of 
paresis,  with  a  question  mark. 

Treatment  and  Result. — The  patient  was  sent  to  the  Watkins  sani- 
tarium, where  he  remained  for  several  months  under  the  care  of  Dr.  King. 
He  had  one  more  convulsion.  He  returned  much  improved  and  gradu- 
ally recovered.  He  has  continued  well  to  the  present  time,  which  is  four 
years  from  the  period  when  I  first  say  him. 

Case  3. — B.  R.,  aged  34,  married;  occupation,  business.  Family  history 
negative. 


THE    CURABILITY   OF   EARLY    PARESIS  25 

History. — He  has  smoked  a  great  deal.  At  i8  he  had  a  luetic  infection 
and  "  secondaries,"  and  was  treated  for  two  years.  Since  that  time  he 
has  had  occasional  periods  of  depression.  In  the  two  months  before 
his  visit  to  me  he  had  again  become  very  much  depressed  and  melancholy. 

Examination. — When  seen  by  me  he  had  no  objective  symptoms  of  any 
form  of  nervous  syphilis.  A  week  or  two  later  he  complained  that  at 
times  he  had  shooting  pains  in  the  legs,  the  right  pupil  was  then  larger 
than  the  left,  but  the  pupils  both  reacted  to  light  and  to  accommodation. 
The  reflexes  were  present,  and   he  had  no  ataxia. 

Subsequent  History. — I  lost  sight  of  him  then,  but  saw  him  again  six 
months  later.  He  then  complained  that  his  memory  was  poor,  and  that 
he  was  unable  to  concentrate  his  mind  at  business.  He  felt  generally 
weak.  His  speech  was  not  perfectly  good,  his  articulation  being  some- 
what thick  at  times,  and  he  now  had  a  distinct  facial  tremor  and  Argyll- 
Robertson  pupils.  His  symptoms  in  general  were  those  of  forgetfulness, 
inability  to  concentrate  the  mind,  occasional  headache,  and  depression  at 
times,  though  this  had  improved  of  late.  This,  it  seemed  to  me,  was 
sufficient  to  justify  a  diagnosis  of  probable  paresis,  and  what  I  at  first 
considered  to  be  merely  a  mild  attack  of  melancholia  seemed  now  to  be 
probably  a   very   serious   condition. 

Treatment. — He  was  placed  on  mercury  and  tonics  and  sent  ofif  to 
rest.  He  steadily  improved,  and  at  the  present  time,  now  three  and  a  half 
years  since  I  last  saw  him,  he  is  perfectly  well  and  has  been  attending  to 
his  work  for  the  last  three  years. 

Remarks. — This  might,  perhaps,  be  interpreted  as  a  case  of  recurrent 
melancholia  with  cerebral  syphilis,  but  I  think  that,  at  least,  with  the 
speech  disturbances,  Argyll-Robertson  pupil  and  facial  tremor  in  mind, 
we  may  assume  that  a  paresis  would  naturally  have  developed. 

Case  4. — J.  R.  K.,  aged  30;  lawyer. 

History. — He  had  an  infection  ten  years  before  and  was  thoroughly 
treated  for  four  years ;  he  had  had  "  secondaries,"  and  during  the  last 
three  years  had  had  throat  trouble,  but  not  of  a  specific  character.  His 
habits  are  good,  except  that  he  has  been  a  very  hard  worker.  Two  years 
before  I  saw  him  he  began  to  have  a  slight  amount  of  ataxia,  and  at  the 
same  time  had  some  deafness.  Six  months  ago  the  ataxia  was  very  much 
better.  One  month  ago  he  had  pain  in  the  eyes  and  diplopia,  due  to  a 
paresis  of  the  right  externus. 

Examination. — The  fundus  was  normal.  He  had  Argyll-Robertson 
pupils.  He  had  great  exaggeration  of  the  patellar  reflexes,  no  ankle 
clonus  nor  Babinski  sign,  some  ataxia  oti  standing  and  locomotion; 
mentally  he  was  very  nervous  and  excitable;  he  was  unable  to  concen- 
trate his  mind  and  had  some  impairment  of  memory. 

Remarks. — The  diagnosis  was  made  of  impending  tabo-paresis.  This 
was  two  years  ago.  Since  then  he  has  been  steadily  improving  and  be- 
came able  to  resume  work.  He  has  now  been  attending  to  his  work  as  a 
lawyer  regularly  for  nearly  two  years,  and  though  still  ataxic  and  not  by 
any  means  well,  his  mental  and  physical  trouble  at  least  has  been  im- 
proved and  arrested. 


26  THE    CURABILITY   OF   EARLY    PARESIS 

Case  5. — S.  B.,  aged  40,  married;  broker.     Family  history  is  good. 

History. — He  has  always  been  a  very  hard-working  man;  he  has 
smoked  immoderately  and  drank  moderately.  He  had  a  luetic  infection 
five  years  ago,  with  "  secondaries,"  which  were  thoroughly  treated.  I 
saw  him  first  in  October,  1903.  For  nearly  a  year  previous  his  mental 
condition  had  been  changing.  His  wife  had  noticed  that  he  was  more 
morose,  less  inclined  to  social  life,  often  unreasonable,  and  irritable  and 
forgetful.  This  was  simply  attributed  to  his  overwork  and  to  the  excite- 
ment of  his  occupation.  In  August,  1903,  he  had  an  epileptiform  attack 
during  the  hours  of  business.  He  recovered  from  this  promptly  and  con- 
tinued his  work.  Later,  in  the  month  of  October,  he  had  another  epi- 
leptiform attack  at  night,  followed  by  a  period  of  maniacal  excitement, 
lasting  for  one  or  two  hours,  in  which  he  became  quite  violent. 

Examination. — I  saw  him  the  next  day.  He  was  a  large,  robust  man, 
with  a  very  healthy  physiognomy.  Mentally  he  seemed  practical'y  normal, 
although  he  was  naturally  much  disturbed  and  apprehensive  over  what 
had  occurred.  He  exhibited  to  me  no  traces  of  forgetfulness  or  ideas 
of  grandeur.  Physically  he  had  distinctly  the  Argyll-Robertson  pupils,  and 
the  knee  jerks  were  exaggerated;  there  was  no  facial  tremor  or  hand 
tremor.  The  writing  was  normal.  He  had  no  lightning  pains  and  no 
paresthesias. 

Subsequent  History. — This  patient  has  now  been  under  observation  for 
over  a  year.  For  some  time  he  showed  an  abnormal  exhaustibility  and 
irritability,  of  both  body  and  mind,  so  that  he  tired  very  easily  in  walking, 
and  had  a  disinclination  to  the  mental  activity  involved  in  social  inter- 
course. His  disposition  was  for  some  time  a  good  deal  changed ;  he 
was  morose,  childish  and  suspicious  of  his  wife,  unreasonable  and  irritable. 
He,  however,  never  showed  any  lack  of  judgment  or  any  forgetfulness  in 
business  affairs ;  he  was  only  childish  in  his  domestic  and  in  certain  social 
relations.  After  about  six  months  the  pupils,  which  had  been  stiff,  became 
normal  the  knee  jerks  remained  about  the  same.  He  had  no  further  con- 
vulsive seizures.  At  the  present  time  this  patient  seems  in  every  way  to 
be  a  normal  man.  He  had  not  had  any  severe  headaches,  no  lightning 
pains,  no  disturbance  of  the  spinal  centers. 

Remarks. — The  probability  of  an  impending  paresis  was  based  on  the 
very  marked  syphilitic  infection,  which  had  been  rather  obstinate  in  his 
case,  and  the  occurrence  of  two  convulsions,  without  previous  headaches, 
the  change  in  his  disposition  and  character,  the  forgetfulness  about  things 
in  his  domestic  relations,  a  carelessness  of  speech  and  manner,  which 
were  not  natural  to  him,  and  the  condition  of  his  pupils.  His  own 
physician.  Dr.  Sherwell  of  Brooklyn,  and  with  whom  I  had  several  talks 
about  the  case,  shared  with  me,  I  think,  though  perhaps  to  a  less  degree, 
the  fear  that  he  might  develop  paresis.  This  was  the  club  held  over  his 
very  impetuous  nature  which  obliged  him  to  change  entirely  his  mode 
of  life,  and  by  reason  of  which  I  think  he  escaped  the  catastrophe. 

Case  6. — H.  B.,  aged  43,  married;  occupation,  broker.  Family  history 
unknown. 


THE   CURABILITY   OF    EARLY    PARESIS  2/ 

History. — The  patient,  from  boyhood,  had  always  been  a  very  hard- 
working, excitable  man.  He  had  lived  a  pretty  fast  life,  drinking  con- 
siderably, but  he  was  not  a  smoker.  He  was  a  man  whose  habits  of 
expression  and  thought  were  always  very  extravagant,  and  whose  business 
dealings  had  been,  normally,  of  a  very  large  kind.  He  denied  any  specific 
infection,  but  I  am  sure  he  had  lived  a  life  which  would  have  exposed 
him  to  it.  In  the  spring  of  1904  he  was  under  a  specially  severe  strain 
and  had  lost  a  good  deal  of  money.  In  June  he  had  a  paresis  of  the  left 
internal  and  right  external  rectus  for  which  he  consulted  Dr.  Koller,  who 
kindly  referred  him  to  me. 

Examination. — When  I  first  saw  him  in  July  he  talked  in  a  very 
extravagant  and  excitable  way,  telling  me  remarkable  stories  about  his 
business,  which  I  believe  were  more  extravagancies  than  actual  delusions, 
and  I  learned  from  his  friends  that  this  was  his  way  of  talking.  He  had 
double  vision  on  account  of  the  internal  rectus  of  the  right  eye.  His 
pupils  were  dilated,  the  left  larger  than  the  right,  and  neither  reacted  to 
light,  but  reacted  to  accommodation ;  the  optic  nerve  and  vision  were 
normal.  He  had  a  fine  tremor  of  the  hands,  but  none  of  the  face  or 
tongue,  and  speech  seemed  clear,  though  occasionally  there  was  a  little 
slip;  his  writing  also  was  fairly  good.  The  knee  jerks  were  somewhat 
exaggerated ;  but  there  was  no  clonus.  He  had  no  ataxia  and  no  light- 
ning pains.  The  bladder  and  sexual  functions  were  normal.  The  memory 
did  not  seem  impaired. 

Treatment. — He  was  given  a  course  of  hypodermic  injections  of 
mercury,  and  then  went  to  Europe  for  six  weeks,  where  he  became  more 
depressed.  On  his  return  he  continued  under  the  treatment  of  Dr.  Koller 
for  his  eye  condition.  He  gradually  improved,  both  mentally  and  physi- 
cally, until  now  his  eye  is  nearly  normal;  he  has  no  tremor,  the  knee  jerks 
are  less  exaggerated,  and  his  mental  condition  is,  perhaps,  better  than 
it  ever  was  in  his  life. 

Remarks. — This  case  might  be  interpreted  as  possibly  one  of  paresis, 
with  a  remission,  but  I  feel  very  confident  that  he  did  not  have  a  frank 
attack  of  paresis  when  he  came  to  see  me,  and  that  he  was  then  suflFering 
only  from  a  sort  of  grandiose  excitement,  with  Argyll-Robertson  pupils, 
and  an  eye  palsy.  A  little  further  delay  and  he  would  have  been  fairly 
a   paretic. 

Case  7. — This  case  was  less  striking  than  the  others,  but,  taken  in 
connection   with  them,   it   has   significance. 

Patient. — J.  H.,  aged  46 ;  family  history  good ;  designer. 

History. — He  had  syphilis  at  the  age  of  23  and  was  treated  thoroughly 
by  specialists.  At  34  he  had  some  mental  depression  and  rheumatic  pains. 
He  was  relieved  by  hypodermic  treatment  with  mercurials.  He  married 
at  37  and  had  a  healthy  child.  At  46  he  had  nervous  attacks  consisting 
of  agitation  and  trembling,  and  he  has  also  had  a  good  deal  of  dyspepsia. 
On  this  was  engrafted  an  "anxious  depression"  or  mild  form  of  hypo- 
chondriacal  melancholia,   which   did  not  keep  him   from  work.     He  had 


28  THE   CURABILITY   OF   EARLY    PARESIS 

no  objective  symptoms,  but  complained  of  his  depression  and  dyspepsia. 
He  gradually  recovered,  but  a  year  later  complained  of  entire  loss  of 
sexual  power,  annoying  failure  to  memory,  difficulty  in  concentration  and 
work,  and  dyspeptic  symptoms.  This  condition  continued  for  a  year, 
with  some  remissions,  but  finally  he  reported  himself  as  practically  well 
of  everything  but  his  sexual  weakness.  He  had  no  symptoms  of  tabes 
at  any  time,  except  his  sexual  weakness.  I  watched  constantly  for  the 
development  of  signs  of  paresis,  but  he  had  only  the  failure  of  memory, 
inability  to  concentrate  his  mind,  and  the  initial  melancholia. 

The  patient,  from  the  time  he  was  34  till  he  was  46,  took  courses  of 
mercury  by  injection.  At  first  he  took  an  injection  every  two  weeks  for 
two  years.  They  acted  on  him  as  a  tonic,  the  effect  lasting  for  a  week  or 
more.     Later  he  took  the  injections  at  much  longer  intervals. 

These  histories,  I  might  repeat,  may  seem  to  present  inconclu- 
sive evidence  of  the  real  existence  of  paresis.  I  think,  however, 
that  most  of  those  who  are  familiar  with  such  cases  will  admit 
that  they  have  seen  paresis  beginning  in  this  way  and  going  on  to 
the  full-fledged  condition.  Such  cases  certainly  have  occurred 
in  my  experience,  and  usually  after  these  initial  symptoms  were 
already  matters  of  the  previous  history. 

The  importance  of  recognizing  paresis  before  it  is  in  a  way 
real  paresis  is  the  very  evident  lesson  of  these  histories. 

Treatment. — In  conclusion,  I  would  say  a  word  only  in  regard 
to  the  treatment  of  these  conditions.  It  seems  to  me  that  if  the 
cases  are  recognized  early  there  is  no  need  of  any  very  novel 
methods  of  treatment ;  there  were  none  employed  here.  I  believe 
that  the  patients  should  at  once  be  turned  entirely  from  their 
former  modes  of  life ;  that  they  should  be  sent  where  they  can  get 
rest  and  fresh  air ;  that  they  should  receive,  if  possible,  hypo- 
dermics of  the  bichlorid  or  salicylate  of  mercury,  and  that  this 
should  be  accompanied  or  followed  with  iodid  of  potassium  and 
tonic  measures.  I  attach  special  importance  to  the  effect  of  hypo- 
dermic medication,  though  all  the  patients  did  not  receive  it.  It 
is  not  always  necessary  to  give  large  doses,  i.  e.,  gr.  ^  twice  a 
week  is  sometimes  enough,  but  this  may  need  to  be  kept  up  for 
two  or  three  months.  In  other  cases  gr.  ii  or  even  gr.  iii  once  or 
twice  a  week  are  required.  The  technic  requires  care.  During 
the  course  of  treatment  there  should  be  a  very  liberal  use  of  luke- 
warm and  hot  bathing  (a  warm  bath  every  day  and  a  hot  bath 
once  or  more  weekly),  and  every  possible  attention  should  be 
given  to  the  general  nutrition  of  the  patient. 


THE    CURABILITY   OF   EARLY    PARESIS  29 

With  these  measures  I  believe  that  a  good  proportion  of  per- 
sons who  are  threatened  with  paresis  can  be  permanently  helped, 
and  it  is  my  hope  that  the  medical  profession  will  become  trained 
to  recognize  these  cases  so  quickly  that  before  many  years  we  may 
get  the  same  gratifying  results  in  paresis  that  we  do  in  tabes. 

I  have  to  express  my  obligations  to  Dr.  Carl  Koller,  Dr.  Alex. 
Duane,-  Dr.  Samuel  Sherwell,  Dr.  Jas.  R.  King,  of  Watkins,  and 
Dr.  Sollace  Mitchell,  of  Jacksonville,  Fla.,  for  referring  some  of 
the  cases  to  me,  for  aid  in  treatment  and  for  furnishing  me  special 
notes  for  the  histories. 

SECOND    PAPER,    READ    NOVEMBER    3,     I909 

In  a  paper  read  before  this  society  five  years  ago,  I  made  a 
contention  that  it  was  possible  to  arrest,  and  probably  to  arrest 
permanently,  certain  cases  of  paresis  when  they  were  observed 
in  the  earliest  stages  and  submitted  to  prompt  and  prolonged  treat- 
ment. To  the  objection  that  the  cases  cited  in  illustration  of  my 
point  were  not  really  cases  of  paresis,  but  of  cerebral  syphilis  or 
"  pseudoparesis,"  I  could  answer  only  by  contending  that  there 
were  no  possible  criteria  by  which  we  could  distinguish  "  pseudo- 
paresis  "  and  certain  forms  of  cerebral  syphilis  from  paresis  itself, 
except  by  saying  that  when  the  patients  recovered  the  cases  were 
false,  and  when  the  patients  died  the  cases  were  real.  In  the 
pseudoparetic  cases  as  in  true  cases,  we  have  headaches,  convul- 
sions, syncopal  and  aphasic  attacks,  disturbance  of  the  pupillary 
reflexes,  tremors,  cranial  nerve  palsies,  even  attacks  of  hemi- 
plegia, lymphocytosis  of  the  cerebrospinal  fluid,  and  positive  reac- 
tion to  Wassermann's  test.  In  each  kind  of  case  also,  we  find 
changes  in  character,  increased  irritability,  inability  to  conduct 
business  afifairs,  defects  of  attention,  somnolence,  confusion  and 
quick  exhaustibility  of  the  mental  processes  on  exertion.  In  cases 
in  which  paresis  is  firmly  established,  with  grandiose  delusions, 
real  dementia,  marked  facial  and  tongue  tremors,  speech  defects, 
involvement  of  the  pyramidal  tracts,  I  make  no  claim  that  the 
disease  can  receive,  at  the  most,  more  than  a  remission. 

The  clinical  facts  on  which  my  contention  is  based  have  been 
so  abundant  and  positive  since  I  first  wrote  on  this  subject  that  it 
seemed  almost  unnecessary  to  emphasize  the  point  further.  I 
am  led  to  do  so,  however,  because  my  view  has  been  misunder- 
stood by  some  who  have  jumped  to  the  conclusion  that  I  have 


30  THE    CURABILITY   OF   EARLY   PARESIS 

asserted  that  paresis  can  be  cured  when  fully  developed ;  also, 
because  my  view  as  to  the  essential  unity  of  nervous  syphilis  and 
parasyphilis  has  been  so  strongly  confirmed  by  the  discovery  of 
the  pale  spirochete  and  the  evidence  of  its  activity  by  Wassermann 
and  other  tests  in  parasyphilitic  conditions. 

The  observations  of  Drs.  Noguchi  and  Moore^  show  that  in 
general  paresis  and  in  cerebral  and  nervous  syphilis,  there  is  a 
positive  reaction  both  to  the  butyric  acid  and  the  Wassermann 
test ;  also  that  there  is  a  practically  equal  evidence  of  lympho- 
cytosis in  the  cerebrospinal  fluids.  Similar  results  were  obtained 
by  Dr.  Rossanoff^  in  his  observations  recently  presented  before 
the  New  York  Academy  of  Medicine.  Dr.  Kaplan's  observations 
presented  at  the  same  time  lead  to  the  same  conclusions.  It  is 
very  well  established,  then,  that  so  far  as  the  blood  and  the  cere- 
brospinal fluid  tests  go,  there  is  no  qualitative  difference  in  the 
reactions  between  paresis  and  so-called  syphilis  of  the  nervous 
system.  There  is  indeed  a  rather  stronger  and  more  positive 
reaction  in  paresis  than  in  the  ordinary  syphilis  of  the  nervous 
system.^ 

^  Noguchi,  H.,  and  Moore,  J.  W.  The  Butyric  Acid  Test  for  Syphilis 
in  the  Diagnosis  of  Metasyphilitic  and  Other  Nervous  Disorders,  Jour. 
Exper.  Med.,  July  17,  1909,  abstr.  in  The  Journal  A.  M.  A.,  Aug.  14, 
1909,  LIII,  591. 

^One  of  Dr.  Rossanoff's  conclusions  is  the  following:  "Inasmuch  as 
the  Wassermann  reaction  and  the  butyric  acid  reactions  seem  to  indicate 
syphilis  only  when  it  exists  in  an  active  or  potentially  active  form, 
their  regular  occurrence  in  general  paresis  would  tend  to  prove  that  that 
disease  is  a  manifestation  of  active  syphilis  of  activity  of  the  Spirochcsta 
pallida.  While  the  evidence  for  this  view  is  not  as  yet  complete,  it  is 
sufficient  to  justify  its  being  used  as  a  basis  of  therapeutic  essay."  Ros- 
sanofF  also  cites  a  case  which  was  diagnosticated  general  paresis.  The 
patient,  however,  recovered  under  treatment  by  mercuric  injections,  where- 
upon the  diagnosis  was  changed  to  cerebral  syphilis.  While  it  cannot  be 
proved,  clinical  experience  in  other  cases  justifies  one  in  saying  that  if 
this  patient  had  not  received  treatment  he  would  have  died  with  the 
symptoms  of  paresis.  Cases  like  this  have  occurred  in  my  experience  and 
have  been  potent  in  forcing  me  to  my  conclusions  as  to  the  nature  and 
management  of  this  disease. 

'Apelt's  later  observations  (Arch.  f.  Psychiat.,  XLVI,  No.  i)  only 
show  that  the  "  Phase  I  "  or  globulin  reaction  does  not  occur  so  often 
in  so-called  cerebral  lues  or  luetic  neurasthenia  as  it  does  in  tabes  and 
paresis,  but  it  does  occur,  and  all  the  serum  and  blood  tests  indicate  only  a 
quantitative,    not  a    qualitative,    difference    between    the   conditions. 


THE    CURABILITY   OF   EARLY    PARESIS  3  I 

The  attempt  to  find  a  test  which  should  distinguish  between 
paresis  and  nervous  syphiHs  or  "  syphilitic  neurasthenia,"  has 
been  made  by  Nonne  and  some  of  his  followers.  The  most 
recent  observations  regarding  the  utility  of  what  is  known  as  the 
Phase  I  Test  of  Nonne  failed  to  show  that  it  is  of  any  distinct 
value  in  distinguishing  between  these  two  conditions  (Noguchi 
and  Moore^).  It  follows,  then,  that  since  there  is  an  essential 
underlying  unity  between  true  paresis  and  "  luetic  neurasthenia," 
"  pseudoparesis,"  "  nervous  syphilis,"  there  is  no  reason  to  sup- 
pose that  if  we  can  cure  one  we  can  not  also  forestall  and  even 
cure  the  other.  This  is  what  I  assert  to  be  possible  and  also,  that 
it  is  not  infrequently  done.  Over  and  over  again,  it  has  been  my 
experience  to  see  luetic  patients  suffering  in  almost  the  same  way, 
nervously  and  mentally,  and  yet,  in  one  case,  after  a  time,  a  true 
paresis  develops,  and  in  the  other  case  it  does  not.  And,  further- 
more, it  has  been  my  experience  to  see  patients  who  have,  clin- 
ically, developed  nearly  all  the  signs  of  paresis,  improved,  and 
remained  practically  well  for  years.* 

The  ordinary,  and  perhaps  I  should  say  asylum  view  of  prog- 
nosis of  paresis,  has  been  recently  presented  by  Dr.  Green,^  who 
made  a  very  careful  study  of  200  cases,  with  reference  to  this  point. 
He  puts  the  limit  of  the  duration  of  the  disease  at  five  years,  this 
occurring  only  in  the  young;  and  he  does  not  speak  even  of  the 
possibility  of  cures,  or  long  remissions.  Such  a  view  expresses, 
I  think,  a  narrow  and  misleading  conception  of  the  malady,  for 
paresis  exists  sometimes  for  years  before  it  reaches  the  alienist 
or  the  hospital.     A  writer  in  one  of  the  medical  weeklies,  during 

*  Sometimes  cases  which  present  mainly  the  appearance  of  cerebral 
syphilis  do  not  improve  under  treatment,  but  go  on  steadily  to  a  fatal 
termination  with  all  the  symptoms  of  paresis.  Two  patients  came  under 
my  care  at  about  the  same  time,  beginning  in  the  same  way.  One  is  now 
apparently  in  active  health ;  the  other  died  of  paretic  dementia.  There 
must,  then,  be  some  plus  factor  in  the  matter  which  is  potent  to  bring 
about  the  unfavorable  result.  This  may  be  inadequate  or  belated  treat- 
ment, or  it  may  be  a  more  degenerate,  unstable  brain.  The  luetic  poison 
quickly  brings  about  hopeless  toxic  changes  in  ablotrophic  cells.  Paresis 
that  is  fatal,  then,  is  that  in  which  the  luetic  infection  is  severe  and  un- 
controllable, or  that  in  which  the  brain-cell,  being  congenitally  weak,  easily 
falls  prey  to  the  toxin.  This  is  the  only  difference  which  I  can  see  be- 
tween cerebral  syphilis  and  parasyphilis." 

'Green,  Jour.  Ment.  Sc,  1908  or  1909. 


32  THE    CURABILITY   OF    EARLY    PARESIS 

the  past  summer,  also  states  unequivocally  that  paresis  is  not  only 
never  cured,  but  surely  and  always  kills,  i.  e.,  it  is  not  even  perma- 
nently arrested.  This  also  expresses  what  I  should  term  a  very 
juvenile  view  of  paresis.  Quite  appropriately  this  writer  quotes 
a  French  novelist  in  support  of  his  position,  but  does  not,  I  think, 
get  any  appreciation  of  some  more  serious  writers.  As  against 
Guy  de  Maupassant,  I  would  quote  Alzheimer,  who  states  that 
he  has  most  positive  evidence  that  paresis  has  remained  unpro- 
gressive  for  many  years. 

I  wish  now  to  put  on  record  the  final  history  of  the  cases  which 
I  reported  five  years  ago,  as  an  illustration  of  arrest  in  preparetic 
states.  The  details  of  the  early  history  of  the  cases  are  given  in 
the  article  referred  to.^  I  shall  add  a  few  further  reports  of  cases 
illustrating  the  clinical  fact  which  I  am  trying  to  prove,  for  I 
know  that  it  is  only  by  the  presentation  of  such  data,  accurately 
and  impartially  given,  that  any  conviction  can  be  produced;  the 
minds  of  many  alienists,  at  least,  seem  to  be  absolutely  fixed  in  an 
attitude  of  pessimism  towards  the  prognosis  of  paresis  in  any  of 
its  stages.  The  cases  are  referred  to  in  the  order  they  were  re- 
ported originally. 

Case  i. — A  broker,  aged  40,  had  an  attack  of  melancholia,  with  the 
somatic  symptoms  indicating  paresis;  that  diagnosis  was  made  in  his 
case.  He  had  tremors  and  Argyll-Rohertson  pupils,  but  he  had  shown  no 
dementia.  He  improved  in  the  sanitarium  and  kept  well  for  three  years 
afterward,  at  which  time  I  reported  the  case.  He  continued  well  for  four 
years  more,  but  he  lived  a  life  of  great  self-indulgence.  He  had  losses 
in  business,  and  finally  developed  genuine  symptoms  of  paresis  and  died 
in  about  a  year.  He  had  had,  therefore,  a  remission  of  seven  years, 
during,  which  he  was  in  every  respect  a  normal  man. 

Case  2. — The  patient  had  continued  well  for  four  years  from  the  time 
when  I  saw  him,  when  his  symptoms  were  marked.  He  had  had  a  luetic 
infection  twelve  years  before.  His  symptoms  were  those  of  convulsions, 
speech  disturbance,  feeble  memory  and  depression.  He  has  continued 
well,  and  is  now  in  active  business.     It  is  eight  years  since  he  recovered. 

Case  3.— A  man,  aged  34,  had  a  speech  disturbance,  Argyll-Robertson 
pupils,  facial  tremor  and  depression  to  the  point  of  melancholia.  When  I 
reported  his  case  he  had  been  attending  to  his  work  and  was  well  for 
the  last  three  years.  I  saw  him  again  in  the  past  year  and  he  had  con- 
tinued well,  so  that  his  remission  has  thus  far  lasted  eight  years. 

Case  4. — A  lawyer,  aged  30,  had  all  the  evidences  of  a  beginning  tabo- 
paresis. The  progress  of  his  disease  was  arrested,  and  for  seven  years  he 
has  been  able  to  do  his  professional  work  with  a  fair  degree  of  success. 


THE    CURABILITY   OF   EARLY    PARESIS  33 

Case  5. — A  broker,  aged  40,  had  had  an  infection.  His  trouble  began 
with  a  violent  epileptic  attack,  followed  by  periods  of  maniacal  excite- 
ment. For  a  year  he  had  a  great  deal  of  mental  irritability  and  de- 
pression, and  a  certain  degree  of  weakness  of  comprehension  and  judg- 
ment.    He  has  now  continued  well  for  six  years  since  the  first  attack. 

Case  6. — A  man,  aged  43,  a  broker,  lost  all  his  money  in  Wall  Street, 
and  then  tried  to  steal  some  to  make  good.  He  developed  a  melancholia 
and  killed  himself. 

Case  7. — This  was  one  of  those  types  of  luetic  infection,  followed  by 
anxious  depression  or  a  mild  form  of  hypochondriacal  melancholia.  For 
twelve  years  the  patient  used  to  have  an  injection  of  mercury,  every  two 
weeks.  It  is  now  nine  years  since  he  was  under  systematic  treatment  and 
he  continues  well. 

The  following  further  cases  illustrate  the  preparetic  state  and 
its  possible  outcome : 

Case  8.— T.  S.,  aged  46,  lawyer,  came  to  me  in  October,  1906.  There 
was  no  hereditary  history  of  importance.  His  father  lived  to  70,  his 
mother  died  at  60,  of  an  accident.  The  patient  was  married  and  had 
three  healthy  children.  He  had  contracted  lues  about  twenty-three  years 
before  coming  under  my  observation.  He  suffered  severely  and,  though 
he  was  treated,  his  health  broke  down  and  he  had  to  rest  from  business. 
After  his  recovery,  i.  e.,  for  about  twenty  years,  he  had  been  quite  well 
and  had  seen  nothing  of  doctors  until  his  present  illness.  About  three 
and  one-half  years  before  I  first  saw  him  he  suffered  from  sexual  weak- 
ness, which  had  gradually  progressed  till  he  had  become  practically  im- 
potent. Of  late  his  bladder  had  been  a  little  weak.  Two  years  before 
coming  under  my  care  he  had  lost  consciousness  suddenly  and  was 
aphasic  for  two  days.  His  capacity  to  speak  in  court  had  been  lessened 
since  then.  One  year  before  the  time  when  I  saw  him  he  had  an 
attack  of  severe  vertigo.  Since  then  his  mental  powers  had  been  lessened 
He  could  not  work  long,  could  not  concentrate,  was  forgetful,  and  had 
attacks  of  vertigo.  He  was  very  somnolent,  sleeping  ten  hours  at  night 
and  in  the  afternoon.  He  was  depressed,  emotional  and  unable  to  do 
much  work  of  any  kind.  His  gait  and  stature  were  normal,  speech 
clear,  handwriting  much  impaired.  The  knee  jerks  and  ankle  jerks  were 
present,  but  uneven.  The  pupils  were  uneven  and  did  not  react  to  light, 
but  did  to  accommodation.  The  left  pupil  was  irregular  in  shape.  The 
patient  had  no  anesthesias,  lightning  pains  or  ataxia.  There  was  tremor  of 
the  hands,  and  the  face  showed  distinct  facial  tremor.  The  main  mental 
symptoms  were  incapacity  to  work,  mental  inadequacy,  defective  memory, 
emotional  excitability  (irritability  and  depression)  and  somnolence.  The 
physical  symptoms  were  changes  in  deep  reflexes,  Argyll-Robertson  pupils, 
facial  tremor,  defects  of  handwriting,  sexual  impotence  without  local 
cause,  as  attested  by  Dr.  Eugene  Fuller,  who  saw  him  in  consultation,  and 

4 


24  THE   CURABILITY   OF   EARLY    PARESIS 

vesical  weakness.  It  was  six  months  before  the  patient  improved  very 
much,  but  at  the  end  of  that  time  he  was  very  much  better,  except 
of  the  sexual  impotence,  and  the  pupils.  His  memory  was  good,  his 
somnolence  and  apathy  better.  A  letter  received  from  him  recently  states 
that  he  is  well,  nearly  three  and  one  half  years  since  I  first  saw  him. 

Such  a  case  as  this  is  illustrative  of  a  type  which  I  have  also 
seen  progress  till  all  the  marks  of  paresis  are  developed. 

Case  9. — J.  E.,  aged  43,  single,  occupation  engineer.  The  history  fur- 
nished by  his  family  physician,  Dr.  Parslow,  is  as  follows:  The  patient's 
father  died  of  Bright's  disease,  at  69;  the  mother  was  living  in  good 
health;  he  had  four  sisters,  all  living.  One  had  epilepsy  for  some  years, 
but  recovered.     Three  aunts  died  of  tuberculosis. 

The  patient  was  always  robust;  used  alcohol  and  tobacco  moderately. 
His  habits  were  excellent,  with  the  exception  of  sexual  excess,  which 
undoubtedly  made  serious  inroads  on  the  patient's  vitahty.  About  three 
weeks  after  connection,  in  the  latter  part  of  1901,  three  hard  chancres 
appeared  on  the  dorsum  of  the  penis,  followed  by  adenitis,  roseola,  etc. 
The  secondary  stage  ran  a  mild  course.  Mercurial  treatment  was  faith- 
fully carried  out.  About  one  year  after  the  primary  sore,  the  patient  was 
stricken  with  left  hemiplegia.  At  this  time,  a  neurologist  saw  him. 
Mercury  by  inunction  was  pushed.  The  motion  of  the  left  arm  was 
seriously  impaired,  but  improved.  After  the  patient  was  up  and  around, 
it  was  noticed  that  he  would  fall  asleep  at  his  work,  especially  after  eating; 
he  was  very  hard  to  arouse  mornings,  even  after  ten  or  twelve  hours' 
sleep.  As  he  was  in  charge  of  complicated  machinery,  his  employers  had 
to  displace  him.  His  friends  noticed  that  he  acted  queerly  at  times.  Dr. 
Parslow  never  noticed  any  delusions  or  hallucinations.  The  patient  wept 
easily,  and  his  mental  depression  was  marked;  his  countenance  changed 
from  a  bright  and  intelligent  to  a  dull  and  stupid  expression.  He  was 
given  iodids  in  large  doses,  but  failed  to  improve. 

When  examined  by  me,  he  still  showed  some  evidences  of  the  left 
hemiplegia,  the  arm  being  somewhat  contractured,  and  there  were  slight 
athetoid  movements  in  the  left  hand.  There  was  no  anesthesia  or  ataxia. 
The  reflexes  were  exaggerated,  more  on  the  left  than  on  the  right,  but 
there  was  no  clonus.  The  pupils  were  sluggish,  but  not  actually  of  the 
Argyll-Robertson  type.  Mentally,  he  was  simply  very  slow  and  forgetful; 
did  not  have  even  the  ordinary  school  knowledge,  nor  could  he  recall  the 
ordinary  events  of  the  day.  He  would  fall  asleep  during  the  daytime 
and  sleep  all  through  the  night.  He  had  no  cranial  nerve  palsies ;  no 
speech  defects,  but  had  a  little  tremor  of  the  face  and  hands.  He  did  not 
show  any  actual  neglect  of  the  person,  and  his  sphincters  were  intact.  He 
could  read  a  little  and  write  imperfectly.  His  condition  had  been  gradu- 
ally getting  worse,  notwithstanding  large  doses  of  the  iodid  of  potassium, 
amounting  to  120  grams  a  day. 


THE   CURABILITY   OF   EARLY    PARESIS  35 

The  patient  was  put  on  hypodermic  injections  of  saUcylate  of  mercury, 
and  gradually  began  to  improve,  and  in  about  six  months  time  he 
seemed  well,  and  went  back  to  his  work. 

I  saw  him  a  year  ago,  five  years  after  my  first  visit.  He  was  then 
well  mentally  in  every  way.  His  speech  was  good,  his  memory  clear, 
and  he  simply  had  some  relics  of  his  old  hemiplegia. 

This  is  a  case  of  cerebral  syphilis,  but  it  was  passing  into  de- 
mentia. The  patient  already  had  tremor,  sluggish  pupils,  exag- 
gerated reflexes.  He  was  dull,  slow,  had  lost  his  knowledge  of 
things,  was  extremely  forgetful,  queer  in  actions,  depressed,  emo- 
tional, somnolent  and  partially  demented. 

Case  10. — E.  A.  M.,  male,  aged  52,  married,  with  two  healthy  children, 
came  to  see  me  first  in  May,  1906,  suffering  from  tabetic  pains.  He  had 
had  a  luetic  infection  at  the  age  of  20,  and  was  thoroughly  treated  for 
two  years;  he  had  had  no  luetic  manifestations  since  then.  He  had  been 
a  hard  worker  at  the  dry-goods  business.  His  habits  were  good ;  he  used 
no  alcohol  or  tobacco  in  excess.  In  1898  he  broke  down  with  what  was 
called  "  nervous  prostration,"  and  was  unable  to  work  for  about  six 
months.  Two  years  later,  in  1900,  he  began  to  have  the  characteristic 
pains  of  tabes,  and  had  been  treated  for  these  symptoms,  and  these  alone, 
since  that  time. 

Status  in  1906:  The  gait  was  normal;  there  was  slight  Brauch-Romberg 
sign  present,  slight  ataxia  of  the  hands  to  the  finger-nose  test.  Argyll- 
Robertson  pupils,  unequal  in  size,  knee  jerks  and  ankle  jerks  absent,  tremor 
of  the  facial  muscles  and  of  the  hands,  no  hypotonia,  no  anesthesia,  bladder 
slow,  sexual  function  very  weak,  tachycardia,  but  no  valvular  lesion.  Men- 
tally, the  patient  was  irritable  and  quite  forgetful;  he  had  a  slightly  exag- 
gerated manner,  was  a  little  exalte,  was  easily  confused,  could  not  play 
cards  without  making  mistakes,  could  not  sign  his  name  on  account  of 
nervousness  and  tremor.  He  was  somnolent  during  the  day,  falling 
asleep  at  his  desk,  was  not  able  to  read  except  for  a  few  moments,  was 
unable  to  do  his  work  well,  becoming  easily  confused  and  exhausted. 
There  was  a  general  change  in  his  character,  so  marked  that  his  wife 
came  to  consult  me  about  it.  He  had  no  delusions,  but  was  somewhat 
depressed. 

The  diagnosis,  in  1906,  was  tabes  and  developing  tabo-paresis.  No- 
vember, 1909,  after  several  months  rest  and  treatment,  part  of  the  time 
at  a  sanitarium,  the  patient  returned  to  business  and  he  has  continued  at 
it  ever  since.  I  have  seen  him  at  intervals  during  the  past  three  and 
a  half  years.  He  is  now  mentally  normal ;  he  is  no  longer  forgetful  and 
can  attend  to  his  work.  He  can  write  and  dictate  readily.  Facial  tremor 
is  gone.  The  tabetic  symptoms  are  the  same,  almost  exactly,  as  they 
were  three  years  ago. 


36  THE    CURABILITY   OF   EARLY    PARESIS 

Case  ii. — W.  D.,  aged  30,  married,  denies  infection.  In  1902  he 
gradually  developed  a  spastic  paraplegia  with  bladder  and  sexual  weakness, 
the  disease  taking  the  course  of  Erb's  syphilitic  spinal  paralysis.  In  the 
fall  the  patient  developed  delusions  of  grandeur,  and  when  examined  by 
me  he  had  all  the  somatic  and  mental  symptoms  of  general  paresis,  with 
facial  tremors,  Argyll-Robertson  pupils,  and  involvement  of  the  pyramidal 
tracts.  This  diagnosis  was  confirmed  by  Dr.  Frederick  Peterson  and  the 
physician  in  charge  of  the  institution  to  which  the  patient  was  committed. 
He  was  insane  and  delusional  for  nearly  a  year,  but  gradually  improved, 
and  has  now  been  practically  well  of  his  mental  trouble  for  over  seven 
years.  He  has  not  known  quite  the  mental  vigor  of  his  former  years, 
and  his  spinal  symptoms  have  remained  about  the  same.  The  total  dura- 
tion of  the  condition  is  now  nearly  eight  years. 

This  is  a  remission  in  general  paresis,  and  it  is  not  one  of  the 
class  of  cases  on  which  I  base  my  remarks.  It  is  admitted  by  all 
that  there  may  be  long  remissions  in  general  paresis. 

I  could  cite  other  cases  from  my  notes,  but  I  prefer  to  get  the 
evidence  of  other  neurologists,  and  Dr.  Joseph  Collins  has  kindly 
placed  the  two  following  cases  at  my  disposal : 

Case  12. — A  man,  aged  45,  stock  broker,  unmarried,  was  seen  May 
31,  1904.  He  had  had  syphiHs  when  23,  an  apparently  moderate  infection, 
treated  by  a  prominent  speciaHst  for  three  years  and  pronounced  cured. 
When  31  years  old  the  patient  had  an  attack  of  diphtheria;  when  38,  an 
attack  of  typhoid   fever. 

The  first  symptoms  of  the  present  disorder,  of  which  the  patient  is 
cognizant,  occurred  in  1903.  He  was  in  bathing.  The  propinquity  of  a 
certain  person  was  responsible  for  extreme  erethism,  followed  after  a 
long  time  by  orgasm.  The  patient  experienced  a  profoundly  disagreeable 
sensation  in  the  head,  and  had  a  feeling  of  confusion  and  syncope.  Fol- 
lowing this,  he  was  in  bed  for  a  fortnight,  and  his  physician  who  treated 
him  said  that  he  had  a  heat-stroke.  After  that  time  the  patient  was 
subject  to  periods  of  profound  depression.  He  lacked  initiative,  was 
moody,  sullen,  unsociable,  and  impotent.  He  frequently  made  mistakes 
in  his  orders  and  thought  he  had  to  give  up  business.  Depression  was  his 
worst  symptom.  The  pupils  were  unequal;  one  knee  jerk  was  absent, 
and  there  was  distinct  slowing  of  speech.  This  man  took  an  enormous 
amount  of  mercury,  by  hypodermic  injections  and  inunctions,  and  is 
today  practically  well.  The  physical  signs  remain  the  same,  save  that  the 
speech  has  become  distinct.  He  is  able  to  transact  his  business  as  well  as 
ever. 

Case  13. — A  man,  aged  46,  had  syphilis  when  21 ;  he  was  rather 
alcoholic.  When  38  years  old  he  developed  symptoms  of  mental  con- 
fusion, associated  at   times   with  violence,  but  depression   was   his  chief 


THE    CURABILITY   OF   EARLY    PARESIS  3/ 

symptom.  Gradually  he  became  indifferent  to  his  family,  exhibited  loss  of 
self-control  and  was  most  easily  excited  and  annoyed.  Examination 
showed  pupils  that  were  unresponsive  to  light,  slight  tremor  of  the  lips, 
tongue  and  hands,  and  exaggerated  knee  jerks.  He  seemed  to  have  in- 
sight into  his  condition  and  explained  his  inability  to  work  by  saying 
that  he  was  weak.  He  would  frequently  make  mistakes  in  writing,  how- 
ever, and  displayed  evidences  of  marked  forgetfulness.  He  was  put 
under  intensive  mercurial  treatment,  and  today,  six  years  after  I  first 
saw  him,  he  is  running  a  store. 

The  question  in  all  these  cases,  of  course,  comes  up  whether 
these  patients  really  were  suffering  from  paresis  in  an  extremely 
early  stage.  Some  authorities  seem  to  take  the  position  that  we 
can  never  be  sure  we  have  a  case  of  paresis  until  the  patient  is 
dead,  and  the  characteristic  anatomic  changes  are  found  in  the 
cortex  of  the  brain.  This  anatomic  test  of  the  existence  of 
paresis  is  an  unworkable  one,  and  would  make  the  talents  and 
acuteness  of  the  clinician  practically  of  no  value.  Besides,  it 
seems  to  me  to  be  utterly  without  foundation.  I  do  not  believe 
that  in  the  very  early  stages  of  paresis  any  anatomic  change  exists 
which  could  be  detected  by  the  microscope,  and  if  we  have  to 
wait  for  our  diagnosis  of  the  disease  until  these  anatomic  changes 
occur,  I  can  well  agree  that  the  prognosis  must  always  be  hope- 
less. But  it  is  my  conviction  that  we  can  recognize  the  malady 
before  any  appreciable  changes  do  occur,  or  at  least,  changes 
which  are  beyond  hope  of  repair  or  arrest.  Let  me  illustrate  this 
position  by  the  following  history : 

Case  14. — A  young  man,  a  lawyer,  aged  33,  was  infected  with  syphilis 
about  eleven  years  before  he  was  seen  by  me.  He  was  treated  for  the 
disease  continuously  for  two  years,  and  after  that  period,  every  six  months, 
for  about  six  years.  He  continued  his  professional  work,  and  was  very 
successful  in  it,  until  about  a  year  before  I  saw  him,  when  he  suffered 
from  symptoms  of  what  was  thought  to  be  neurasthenia.  He  was  treated 
on  this  basis  and  went  out  West,  took  active  exercise  on  horseback.  He 
improved  somewhat,  but  then  became  considerably  worse,  and  was  finally 
brought  to  me  in  January,  1909,  when  he  had  distinctly  the  symptoms  of 
paresis — forgetfulness,  inability  to  concentrate,  confusion  of  ideas,  irrita- 
bility, a  good  deal  of  mental  depression,  and  certain  almost  delusional 
ideas  regarding  the  way  in  which  he  was  treated  by  his  friends.  Phys- 
ically, he  had  distinct  and  characteristic  dysarthria,  tremors  of  the  face 
and  hands,  exaggerated  reflexes,  and  Argyll-Robertson  pupils.  The 
Wassermann  test  was  positive.     He  improved  a  little  for  a  time,  but  at 


38  THE   CURABILITY   OF   EARLY    PARESIS 

the  end  of  the  following  summer  he  was  distinctly  demented  and  delu- 
sional, and  had  all  the  characteristic  physical  symptoms  of  general  paresis. 
These  progressed,  and  he  is  now  in  the  third  stage  of  the  malady. 

The  point  of  interest  in  this  case  is  this :  On  inquiring  carefully 
about  the  patient's  earlier  years,  I  found  that  five  years  before  I 
had  seen  him,  he  had  had  an  attack  of  mental  depression,  of  a 
somewhat  hypochondriacal  type,  such  as  so  frequently  ushers  in 
paresis.  This  had  occurred  without  special  cause,  and  in  a  man 
whose  habits  were  good,  and  who  had  inherited  a  sound  consti- 
tution. I  further  learned  that  after  he  recovered  from  this 
depression  he  had  been  a  little  different  in  temperament  and  char- 
acter, a  little  more  irritable  and  unreasonable,  a  little  more  ego- 
tistical and  expansive  than  usual,  his  friends  thinking  that  he  was 
simply  rather  more  conceited  and  difficult  to  get  on  with  than 
before.  But,  in  the  light  of  subsequent  events,  it  seems  clear  that 
these  were  the  mental  forerunners  of  his  later  attack,  because 
when  the  later  attack  came  on,  all  these  characteristics  were  simply 
very  greatly  exaggerated.  Thus,  it  seems  that  this  attack  of 
paresis  can  be  traced  back  to  a  period  of  five  years,  during  which 
time  the  patient  achieved  a  really  brilliant  success  in  his  pro- 
fession, transacting  his  work  effectively,  and  not  suffering  from 
any  physical  troubles  whatever.  It  seems  incredible  that  during 
all  these  years  of  successful  professional  work  and  social  activity, 
he  had  any  serious  degenerative  changes  in  the  cortex  of  the  brain, 
which  changes  are  supposed  to  be  necessary  to  enable  one  to  make 
a  diagnosis  of  paresis. 

If  the  history  of  cases  of  paresis  could  be  traced  back  in  all 
instances,  to  the  very  remotest  beginning,  I  believe  that  in  a  good 
many  instances  this  prolonged  preliminary  period  of  slight  mental 
perversion  might  be  discovered,  and  in  this  case  I  think  that  if 
treatment  had  been  undertaken  along  proper  lines  three  years 
before,  or  two  years  before,  the  malady  might  have  been  kept  in 
check. 

The  onset  of  a  parasyphilis,  occurring  in  persons  who  have  had 
an  infection,  takes  place  in  different  ways  as  follows : 

I.  Acute  symptoms  of  syphilitic  exudates  in  the  brain,  ending 
promptly  or  later  in  paresis,  or  ending  in  cure,  with  or  without 
mental  symptoms,  or  ending  in  some  deterioration  with  final 
serious  cerebral  vascular  changes. 


THE   CURABILITY   OF   EARLY    PARESIS  39 

2.  Acute  mental  symptoms,  maniac  or  melancholic,  ending  in 
cure  or  paresis. 

3.  Tabetic  and  paretic  symptoms,  ending  in  taboparesis  or  in 
tabes  with  arrest  of  paresis. 

4.  Insidious  mental  and  physical  deterioration,  ending  in  paresis. 
The  above  initial  conditions  all  may  or  may  not  end  in  paresis, 

depending  on  treatment,  the  constitution  of  the  patient,  and  the 
intensity  of  the  infection.  Often  they  go  on  until  nearly  every 
symptom  of  paresis  appears,  yet  they  are  even  then  arrested.  The 
clinical  phenomena,  from  the  beginning  to  near  the  end,  are  pro- 
duced by  the  same  pathologic  agent,  and  often  can  be  controlled 
by  treatment,  even  when  the  signs  are  ominously  identical  with 
early  symptoms  of  general  paralysis.  This  is  what  I  mean  by 
"  cure  of  early  paresis." 


THE  DIAGNOSIS   OF  GENERAL  PARALYSIS^ 
By  C.  Macfie  Campbell,  M.D. 

ASSISTANT    PHYSICIAN     BLOOMINGDALE     HOSPITAL,     NEW    YORK 

The  differential  diagnosis  of  general  paralysis  is  an  extremely 
wide  subject  in  view  of  the  polymorphous  character  of  the  dis- 
ease. Not  only  do  various  forms  of  organic  brain  disease  present 
clinical  pictures  difficult  to  distinguish  from  general  paralysis,  but 
the  latter  may  first  manifest  itself  in  a  form  difficult  to  distin- 
guish from  that  of  one  of  the  so-called  functional  psychoses ;  thus 
a  manic  attack  may  be  the  first  expression  of  a  general  paralysis. 

The  question  of  the  early  diagnosis  of  general  paralysis,  and 
the  discussion  of  those  symptoms  accompanying  a  so-called  func- 
tional symptom-complex  which  enable  one  to  diagnose  the  para- 
lytic process  underlying  it,  will  no  doubt  be  taken  up  by  others. 

I  propose  to  contribute  to  the  discussion  several  cases  where 
the  difficulty  of  diagnosis  was  not  merely  transitory,  nor  due  to 
the  disease  being  in  an  incipient  stage ;  but  where  in  a  well- 
advanced  stage  of  the  disease  it  was  extremely  difficult  to  know 
how  much  weight  to  lay  upon  the  various  symptoms,  and  to  come 
to  a  conclusion  as  to  the  process  at  the  bottom  of  the  disease. 

It  will  be  necessary  in  regard  to  some  of  these  cases  to  refer 
to  the  result  of  the  anatomical  examination  which  decided  the 
diagnosis ;  before  doing  so,  and  in  order  not  to  beg  the  question, 
one  must  first  be  clear  as  to  the  present  state  of  our  knowledge  of 
the  histopathology  of  general  paralysis. 

The  most  satisfactory  and  most  recent  statement  on  that  topic 
is  to  be  found  in  the  first  volume  of  Nissl's  publications  from  the 
laboratory  of  the  Heidelberg  clinic.  The  volume  contains  the 
results  of  the  work  of  Alzheimer  and  of  Nissl ;  both,  working  at 
the  same  question  upon  independent  material,  came  to  the  same 
conclusion,  that  in  general  paralysis  there  are  always  characteristic 
histopathological  changes  which  enable  a  positive  diagnosis  to  be 
made.  A  slight  reservation  must  be  made  with  regard  to  certain 
cases  of  idiocy  upon  the  basis  of  a  non-purulent  encephalitis,  with 

^  Read  before  the  New  York  Psychiatrical  Society,  November  7,  1906. 

41 


42  THE   DIAGNOSIS   OF   GENERAL   PARALYSIS 

regard  to  which  there  is  not  as  yet  sufficient  material  for  definite 
statements  to  be  made.  In  the  work  referred  to,  Nissl  discusses 
in  great  detail  certain  morphological  questions,  and  emphasizes 
the  wide  biological  and  pathological  issues,  while  Alzheimer  limits 
himself  more  strictly  to  the  immediate  needs  of  histopathological 
and  clinical  differentiation.  Reference,  therefore,  will  be  made 
chiefly  to  the  work  of  Alzheimer. 

The  material  which  Alzheimer  used  consisted  of  170  consecu- 
tive cases  of  clinically  undoubted  general  paralysis ;  in  every  case 
he  found  certain  histological  changes  in  the  cortex ;  he  concluded, 
therefore,  that  he  had  a  definite  anatomical  criterion  to  apply  to 
all  cases  of  doubtful  clinical  diagnosis. 

This  anatomical  criterion  is  not  claimed  as  forming  the  essence 
of  the  paralytic  process ;  the  same  cortical  changes  were  found  by 
Nissl  in  a  dog  and  two  rabbits ;  they  form,  however,  a  trustworthy 
empirical  criterion,  which  every  case  claimed  as  general  paralysis 
must  satisfy. 

Macroscopic  examination  is  not  sufficient  to  settle  conclusively 
a  disputed  case;  at  the  autopsy  the  brain  of  a  general  paralytic 
may  show  no  macroscopic  evidence  of  general  paralysis;  on  the 
other  hand  Alzheimer  refers  to  a  case  diagnosed  in  life  as  senile 
dementia,  which  presented  at  the  autopsy  thickening  of  the  cal- 
varium  with  disappearance  of  the  diploe,  thickening  and  opacity 
of  the  pia  with  pial  collections  of  fluid,  hydrocephalus  internus 
and  externus,  ependymal  granulations,  marked  atrophy  of  the 
brain,  especially  in  the  frontal  region ;  microscopical  examination, 
however,  confirmed  the  clinical  diagnosis  of  senile  dementia. 
Such  a  case  demonstrates  the  necessity  of  microscopical  exami- 
nation. 

The  following  is  a  brief  summary  of  the  histological  changes 
characteristic  of  general  paralysis. 

I.  In  every  case  the  pia  mater  shows  diffuse  changes,  usually 
most  marked  over  the  frontal  lobe ;  these  changes  consist  essen- 
tially of  an  infiltration  of  the  pia  with  cellular  elements,  plasma- 
cells,  lymphocytes  and  mast-cells ;  in  addition  the  vessel-walls  show 
progressive  and  regressive  changes. 

With  regard  to  the  cortex  in  general  paralysis  it  is  convenient 
to  discuss  first  the  mesodermal  elements  and  then  the  ectodermal 
elements. 


THE   DIAGNOSIS   OF   GENERAL   PARALYSIS  43 

2.  In  every  case  there  is  proliferation  of  the  endothehal  cells 
of  the  vessels  with  a  marked  tendency  to  the  new  formation  of 
vessels  through  sprouting  and  vascularization  of  the  proliferated 
intima.  There  is  increase  of  the  elastica  and  proliferation  of  the 
adventitia.  There  is  widening  and  infiltration  of  the  lymph  spaces, 
which  exist  in  the  adventitial  coat  of  the  vessel  wall.  Among  the 
infiltrating  cells,  plasma-cells  are  the  most  numerous:  they  are 
never  absent  in  a  case  of  general  paralysis,  even  in  the  most 
acute.  Lymphocytes  and  mast-cells  may  also  be  found  in  the 
infiltrate.  In  advanced  cases  the  vessel  walls  show  regressive 
changes.  Regularly  in  general  paralysis,  we  find  long  rod-shaped 
or  sausage-shaped  cells  in  the  cortex,  their  long  diameter  tending 
to  run  parallel  with  the  medullary  rays. 

As  to  the  ectodermal  elements : 

3.  The  nerve-cells  show  a  great  variety  of  degenerative  forms, 
the  meaning  of  which  is  as  yet  quite  obscure ;  in  advanced  cases 
the  nerve  cells  have  in  part  disappeared.  The  usual  orderly 
arrangement  of  the  cells  in  the  cortex  is  more  or  less  disturbed. 
There  is  usually  a  considerable  degeneration  of  the  medullated 
fibers  in  the  cortex. 

With  regard  to  the  non-nervous  ectodermal  tissue,  i.  e.,  the 
neuroglia : 

4.  There  is  always  a  marked  proliferation  of  the  glia ;  this  pro- 
liferation leads  at  first  to  the  formation  of  numerous  large  glia 
cells  which  form  a  large  number  of  fibers,  and,  in  very  advanced 
cases,  dense  tissue  of  thick  glia  fibers.  The  most  marked  increase 
is  situated  in  the  molecular  layer  and  along  the  vessel  sheaths. 

The  changes  in  the  rest  of  the  nervous  system  in  general  paral- 
ysis, the  nature  and  degree  of  aflection  of  the  central  ganglia, 
cerebellum,  cord,  etc.,  need  not  at  present  be  discussed. 

Lissauer  has  described  cases  of  atypical  general  paralysis,  in 
which  focal  symptoms  precede  the  symptoms  of  mental  disorder; 
in  these  cases  one  frequently  has  from  time  to  time  apoplectiform 
attacks,  each  attack  leaving  the  same  residual  defect — hemiparesis, 
hemiplegia,  aphasia — which  is  frequently  transitory. 

In  such  cases  the  typical  cortical  changes  of  general  paralysis 
are  found,  the  focal  symptoms  not  being  due  to  the  addition  of 
syphilitic  or  arteriosclerotic  or  other  lesions,  but  to  the  unusual 
severity  of  the  process  in  certain  areas,  the  central  convolutions, 


44  THE   DIAGNOSIS   OF   GENERAL   PARALYSIS 

the  temporal  lobe,  etc.  In  other  cases,  where  the  distribution  of 
the  process  has  at  first  been  the  usual  one,  later  in  the  disease  the 
changes  may  become  most  severe  in  the  posterior  half  of  the 
cortex  and  focal  symptoms  may  then  develop.  Transition  forms 
between  the  typical  and  the  atypical  general  paralysis  are  numerous. 

In  certain  cases  we  find  general  paralysis  associated  with  tabes, 
and  that  may  occur  in  two  ways :  tabetic  changes  may  develop 
during  the  course  of  general  paralysis,  or  a  person,  who  has  for 
long  been  a  tabetic,  may  later  show  signs  of  general  paralysis. 
The  tabes  of  a  general  paralytic  is  histologically  little  diflferent 
from  that  of  a  non-paralytic ;  dififerent  systems  in  the  posterior 
columns,  however,  tend  to  be  first  affected  and  a  slight  cellular 
exudate  is  frequently  seen  in  the  posterior  columns  of  the  general 
paralytic  with  tabes,  but  has  not  been  observed  by  Alzheimer  in 
tabes  itself. 

In  general  paralysis,  there  is  a  constant  histopathological  pic- 
ture. Can  one  always  distinguish  this  from  the  picture  found  in 
cases  of  alcoholism,  senile  dementia,  arteriosclerotic  brain  disorder 
and  brain  syphilis?  In  other  words,  in  doubtful  clinical  cases, 
will  microscopical  examination  enable  one  to  differentiate  between 
these  groups? 

With  regard  to  the  first  three  groups  there  is  little  difficulty, 
and  it  is  not  necessary  to  go  over  the  differences  in  the  degenera- 
tive changes  found  in  each ;  a  diffuse  perivascular  infiltrate  with 
plasma  cells  is  not  found  in  any  of  these  conditions. 

The  differential  diagnosis  between  general  paralysis  and  brain 
syphilis  is  more  difficult,  but  is,  however,  always  possible ;  at  least, 
one  can  always  say  whether  the  case  is  general  paralysis  or  not; 
it  is  not  always  easy  to  determine  whether,  in  addition,  there 
is  a  syphilitic  element  present.  Brain  syphilis  is  a  general  term 
which  includes  gumma  of  the  brain,  syphilitic  endarteritis  of  the 
cerebral  vessels,  either  of  the  large  vessels  (Heubner's  form),  or 
of  the  terminal  vessels  (Nissl's  non-inflammatory  form  of  brain 
syphilis),  and  finally  syphilitic  meningo-encephalitis,  with  or  with- 
out gummatous  formation.  Each  of  these  presents  a  definite  histo- 
pathological picture  and  can  be  separated  from  general  paralysis. 
The  most  difficult  cases  are  those  belonging  to  the  last  group — i.  e., 
syphilitic  meningo-encephalitis  ;  careful  microscopical  examination 
enables  one  here,  too,  to  separate  the  two  conditions.    The  pictures  in 


THE   DIAGNOSIS   OF   GENERAL   PARALYSIS  45 

Alzheimer's  work  illustrate  well  the  two  conditions.  The  meningo- 
encephalitis shows  the  most  marked  infiltration  in  the  pia,  which, 
along  with  the  vessel  walls  and  the  cranial  nerves  passing  through 
the  membranes,  is  infiltrated  with  lymphocytes.  The  process 
spreads  from  the  pia  into  the  cortex,  afifecting  the  superficial 
layers  more  than  the  deeper,  sometimes  obliterating  the  border 
between  pia  and  cortex.  Where  the  affection  of  the  pia  is  local- 
ized the  cortical  changes  show  a  similarly  circumscribed  distri- 
bution. The  condition  may  be  complicated  by  gummatous  nodes, 
and  by  softening  due  to  thrombosis. 

Such  a  picture  is  quite  different  from  that  of  general  paralysis 
where  the  severity  of  the  cortical  change  does  not  necessarily  cor- 
respond with  that  of  the  meningeal  change  in  the  same  neighbor- 
hood, and  where  the  cortex  shows  parenchymatous  degeneration 
and  vascular  changes  diffusely  distributed  throughout  the  whole 
cortex.  The  behavior  of  the  cells  of  the  infiltrate  is  different  in 
the  two  conditions.  In  the  syphilitic  meningitis  the  infiltrate, 
composed  chiefly  of  lymphocytes,  is  not  arrested  by  the  limits  of 
the  vessel  walls  nor  of  the  nerves  which  pass  through  the  pia,  it 
penetrates  both.  The  cell  changes  in  the  pia  do  not  show  the 
variety  of  progressive  and  regressive  forms  found  in  general 
paralysis. 

A  syphilitic  meningo-encephalitis  of  the  convexity  is  almost 
always  accompanied  by  a  syphilitic  meningo-myelitis. 

Mahaim  says  that  it  is  impossible  to  differentiate  general  paral- 
ysis from  diffuse  brain  syphilis ;  but  the  form  which  causes  most 
difficulty  is  that  already  discussed  and  the  individuality  of  which 
has  been  established.  His  views  are  based  upon  an  insufficient 
study  of  the  infiltrate  in  the  various  conditions. 

Klippel  considers  general  paralysis  a  clinical  syndrome  which 
may  arise  on  an  alcoholic,  syphilitic,  arteriosclerotic  or  other 
basis.  He  bases  this  statement  upon  quite  erroneous  ideas,  the 
criticism  of  which  would  necessitate  a  somewhat  detailed  state- 
ment of  his  position.  As  a  matter  of  fact,  the  present  state  of 
our  knowledge  of  pathological  anatomy  has  enabled  us  to  dis- 
tinctly separate  the  various  processes,  arteriosclerotic,  senile,  alco- 
holic, syphilitic  and  general  paralytic;  if  then,  clinically,  one  is 
not  always  able  to  distinguish  between  these  groups,  that  is  no 
reason  for  refusing  to  recognize  them  as  different  conditions ;  it 


46  THE  DIAGNOSIS   OF   GENERAL   PARALYSIS 

is  simply  a  reason  to  push  further  our  dinical  analysis.  The  clin- 
ical differentiation  of  these  groups  is  not  so  far  forward  as  the 
anatomical  differentiation.  There  is  an  urgent  necessity  for  well- 
analyzed  clinical  material,  so  that  we  can  make  full  use  of  the 
assistance  which  microscopical  examination  offers  us.  From  this 
point  of  view  the  following  cases  are  presented. 

Case  i. — William  C. ;  47  years  of  age,  admitted  to  Manhattan  State 
Hospital  on  August  25,  1905;  died  May  3,  1906. 

His  father  was  alcoholic;  he  himself  was  a  neurotic  child,  had  night 
terrors,  walked  and  talked  in  his  sleep.  He  developed  normally,  later 
became  addicted  to  alcohol,  married  in  1891,  having  had  a  chancre  six 
months  previously,  for  which  he  received  only  three  months'  treatment. 
He  infected  his  wife,  and  she  had  a  disastrous  series  of  pregnancies,  but 
finally  a  living  and  healthy  child.  Ever  since  his  marriage,  the  patient 
drank  immoderately,  indulged  in  excessive  sexual  intercourse,  tormented 
his  wife  with  his  morbid  jealousy  and  suspicions,  so  that  she  left  him 
more  than  once.  As  far  back  as  1897,  he  would  suspect  poison,  and 
imagine  that  his  relatives  and  associates  dealt  unfairly  with  him;  his 
waking  thought  was  apparently  considerably  influenced  by  dreams. 

Focal  symptoms  first  came  on  in  1900.  In  1900,  towards  the  end  of 
summer,  his  wife  noticed  squint  of  the  right  eye;  this  persisted  till 
November.  In  September  of  the  same  year,  he  had  an  attack  of  dysar- 
thria and  staggering;  no  definite  weakness  of  the  limbs  of  either  side  was 
noticed.  He  recovered  after  two  months  in  bed,  his  speech  returning  ap- 
parently to  its  normal  condition.     He  was  able  to  resume  work. 

1901.  Again  fatigued  and  without  appetite;  he  lost  the  power  of  his 
right  leg  "  from  the  knee  downwards,"  the  weakness  not  being  abrupt 
in  onset  but  coming  on  in  the  course  of  a  few  days ;  speech  was  thick, 

1901-1903.  Unable  to  work;  he  dragged  the  right  leg;  two  or  three 
sudden  attacks  of  paralysis  of  the  right  arm  of  one  half  day's  duration, 
with  weakness  of  the  right  side  for  about  a  week. 

1903.  One  day  he  suddenly  fell;  when  seen  one  hour  later,  he  was  a 
little  excited,  able  to  speak,  his  left  arm  suddenly  became  paralyzed,  he 
could  not  speak  for  one  hour ;  he  was  then  able  to  walk,  went  to  work  the 
next  day. 

1903-1905.  Worked  as  night  watchman,  gradually  became  weaker,  did 
not  recognize  that  he  was  an  invalid,  made  light  of  his  hemiplegia. 

1904.  Occasional  difficulty  in  controlling  his  urine. 

1905.  July.  One  day  at  noon  he  was  found  unconscious;  half  an 
hour  later  he  was  excited,  but  unable  to  speak,  he  made  signs,  then  said 
"  that's  better."  For  one  week  he  was  semi-conscious,  disoriented,  didn't 
know  his  wife;  he  remained  at  home  for  five  weeks,  was  disoriented,  had 
hallucinations  of  sight — "didn't  you  see  them  men?" — thought  medicine 
was  poison.  In  Bellevue  Hospital  he  thought  he  was  in  St.  Stephen's 
Church,  had  no  idea  of  why  he  was  there. 


THE   DIAGNOSIS   OF   GENERAL   PARALYSIS  47 

On  admission  to  M.  S.  H.  he  was  at  first  excited  and  pugnacious,  but 
on  examination  quiet  and  agreeable,  anxious  to  go  home;  he  was  able  to 
maintain  a  conversation.  He  was  happy,  felt  first-rate,  did  not  resent 
being  with  crazy  people ;  "  this  is  Manhattan  Life  Insurance-Bellevue 
Hospital,"  he  gave  the  date  correctly.  He  had  fair  memory  of  remote 
and  recent  events,  but  his  dates  showed  discrepancies,  e.  g.,  "  this  is  1906 
— born  in  1862 — 47  years  old."  Dilapidation  of  general  knowledge;  poor 
retention ;  no  insight. 

August-October.  Mildly  demented,  whimpering  easily  over  his  de- 
tention. 

October  25th.  Ptosis  of  the  left  eye  developed,  became  complete  in  a 
week,   cleared   up  after   four   weeks. 

Physical  Status. — October  25,  1905.  There  was  weakness  of  the  right 
face,  arm  and  leg.  Knee-jerks  and  Achilles-jerks  exaggerated,  especially 
the  right.  The  gait  was  rather  unsteady  as  well  as  having  the  "  mow- 
ing" character.  Babinski  reflex  on  both  sides.  Slight  ptosis  of  the  left 
eye;  left  pupil  dilated,  did  not  react  to  light  nor  on  accommodation;  right 
pupil  smaller,  reacted  sluggishly  to  light.  Fundi  normal.  Speech:  slur- 
ring, slightly  sticking,  without  omissions  or  transpositions,  but  with  occa- 
sional insertion  of  r.  Writing:  tremulous  with  omissions  and  distortions, 
e.  g.,  "  meth-espical"  (methodist  episcopal),  "  bittililery "  (artillery). 
There  was  no  gross  sensory  disorder.  Lymphocytosis  of  the  cerebro- 
spinal fluid. 

During  his  stay  in  hospital,  the  patient  continued  to  present  this  picture 
of  mild  general  dilapidation,  with  no  adequate  realization  of  the  mental 
and  physical  impairment,  but  showing  no  definite  expansiveness  nor 
other  abnormal  mental   trend  while   in  hospital. 

On  April  30,  1906,  the  patient  had  a  general  convulsion,  became  un- 
conscious; he  died  on  May  3. 

The  question  whether  one  had  a  right  in  this  case  to  consider 
a  diagnosis  of  general  paralysis  as  established  was  discussed 
during  the  lifetime  of  the  patient.  Our  present  knowledge  of 
the  symptoms  of  brain  syphilis  is  inadequate  and  based  on  a  very 
limited  material,  and  it  was  felt  that  to  exclude  the  diagnosis  of 
brain  syphilis  altogether  was  to  assume  a  knowledge  of  the  same 
which  we  are  far  from  possessing. 

The  possibility  of  brain  syphilis  was  suggested  by  the  variety  of 
the  neurological  symptoms — squint  in  1900,  a  series  of  rightrsided 
attacks  with  dysarthria  from  1901  to  1903,  transitory  paralysis 
of  the  left  arm  in  1903  (if  the  wife's  statement  can  be  relied  on), 
the  apoplectiform  attack  preceding  commitment,  the  transitory 
ptosis  of  the  left  eye  which  developed  in  hospital.  Such  a  train 
of  symptoms  seemed  in  keeping  with  what  we  know  of  the  course 


48  THE  DIAGNOSIS   OF   GENERAL   PARALYSIS 

of  brain  syphilis,  and  it  was  considered  possible  that  the  under- 
lying anatomical  process  might  be  a  syphilitic  meningo-encephalitis 
with  syphilitic  endarteritis,  the  hemiplegic  attacks  being  due  to 
the  vascular  changes ;  the  mild  dementia  might  then  be  regarded 
as  an  ordinary  post-apoplectic  dementia. 

This  hypothesis,  however,  did  not  seem  to  explain  various  fea- 
tures in  the  case.  The  want  of  insight  into  his  mental  and  physical 
impairment,  and  his  general  optimism  seemed  to  be  more  than  is 
usual  in  a  non-paralytic  dementia;  it  is  true  that  in  some  cases 
of  the  latter  a  similar  attitude  may  be  seen,  and  the  difference  in 
degree  is  difficult  to  estimate.  Repeated  tests  of  his  memory 
showed  a  striking  difficulty  in  handling  dates,  and  an  inability  to 
correct  discrepancies;  e.  g. :  Age?  "48."  Present  year?  "1906, 
then  I  must  be  58."  Are  you  58?  "  No — that  would  be  1858 — I 
would  be  50  then — this  is  only  6 — that  would  be  right,  58  years 
of  age."  58  years  of  age?  "Yes,  sir."  Are  you  50  years  of  age  ? 
"  No,  I  would  be  48 — I  made  a  mistake — 48  and  58 — 1858,  and 
then  50 — 40  more — would  be  1906, — wouldn't  it — 18  and  46 
more."  At  the  same  time  the  patient  showed  great  pertinacity  in 
trying  to  correct  discrepancies. 

The  speech  also  (e.  g.,  bittililery)  seemed  to  show  a  more  pro- 
found defect  in  the  grasp  of  words  than  is  usually  met  with  in 
brain  syphilis. 

The  physical  symptom-complex  seemed  consistent  with  either 
view  of  the  case,  although  the  variety  of  the  neurological  symp- 
toms pointed  rather  toward  brain  syphilis. 

On  the  basis  of  the  above  analysis,  the  conclusion  was  that  the 
patient  was  probably  a  case  of  general  paralysis,  but  that,  in  so 
far  as  we  are  not  entitled  to  deny  the  possibility  of  the  presence 
of  the  above  mental  defects  in  brain  syphilis,  and  in  view  of  the 
neurological  course,  the  diagnosis  of  general  paralysis  was  not 
considered  as  established. 

At  the  autopsy  there  were  noted  slight  atrophy  of  the  frontal 
region,  rather  more  marked  on  the  left  side,  slight  general  thick- 
ening of  the  pia,  granulations  in  the  fourth  ventricle.  In  the  knee 
of  the  right  internal  capsule  there  was  an  old  focus  of  softening, 
and  another  in  the  left  side  of  the  hind  brain,  involving  the  pyra- 
midal fibers.  There  was  a  gumma  in  the  left  centrum  semiovale, 
connected  with  the  pia  of  the  insula,  another  in  the  right  parieto- 


THE   DIAGNOSIS   OF   GENERAL   PARALYSIS  49 

occipital  fissure.      Histological  examination  showed  a  syphilitic 
meningitis,  of  varying  grade,  with  slight  extension  into  the  cortex. 
The  case,  therefore,  was  one  of  cerebral  syphilis. 

Case  2.— J.  L.  W.;  43;  admitted  to  M.  S.  H.  August  4,  1906;  died 
August  26,  1906. 

The  patient  was  a  journalist,  who,  in  1898,  at  the  age  of  35,  had  a 
chancre  for  which  he  was  treated  for  4-6  months.  In  the  summer  of 
1901  he  had  diplopia,  which  improved  with  two  months'  treatment.  In 
April,  1902,  he  one  day  lost  power  in  his  left  arm;  next  day  his  whole 
left  side  was  affected ;  there  was  no  loss  of  consciousness.  He  was  taken 
to  a  hospital  where  complete  left  hemiplegia  without  impairment  of 
tactile  sensibiHty  was  observed.  He  was  treated  with  potassium  iodide, 
was  discharged  after  four  weeks  as  improved;  the  diagnosis  was  cerebral 
syphilis. 

November,  1902,  he  retired  one  night  dizzy  and  nauseated;  during  the 
night  he  woke  up  with  left-sided  paralysis;  there  was  twitching  of  the 
left  arm,  leg  and  side  of  the  face  for  four  hours ;  he  could  not  speak, 
was  conscious,  attracted  attention  by  knocking  down  a  screen. 

He  was  again  treated  in  the  same  hospital  with  sodium  iodide,  and 
hypodermics  of  bichloride  of  mercury,  was  discharged  after  19  days, 
improved ;  diagnosis :  cerebral  syphilis. 

After  discharge  he  only  occasionally  took  medicine;  from  time  to 
time  he  had  headache.  In  October,  1905,  the  patient  noticed  that  the  left 
leg  was  becoming  weaker;  he  received  glutal  injections  for  one  month. 
In  the  autumn  of  1905  his  work  apparently  was  inefficient,  he  was  dis- 
charged from  the  paper  on  which  he  worked.  In  January,  1906,  he  twice 
(on  the  fifteenth  and  twenty-second)  fell  abruptly  without  dizziness  or 
loss  of  consciousness;  he  was  able  to  raise  himself  and  walk  home. 

He  was  admitted  to  Bellevue  Hospital,  January  25,  complaining  of 
having  fallen  in  the  street,  of  progressive  weakness  of  the  left  leg,  and 
of  loss  of  memory.  The  diagnosis  of  cerebral  syphilis  was  made 
and  the  patient  was  given  potassium  iodide  up  to  39c  grains  a  day, 
and  was  also  treated  with  hypodermic  mercurial  injections.  From  the 
beginning  of  his  stay  in  B.  H.  he  showed  mental  symptoms,  was  irrational. 
Soon  after  admission,  he  tried  to  get  out  of  bed  and  take  a  stroll  along  the 
river.  He  was  restless  and  noisy  at  times,  sometimes  mildly  delirious, 
rambling  about  imaginary  things.  In  February  he  had  four  convulsions 
one  night.  During  the  latter  half  of  his  stay  in  Bellevue  he  was  rather 
irritable,  and  several  times  tried  to  escape.  In  June  he  was  noticed  to 
stammer  badly,  saw  objects  dimly,  was  generally  muddled.  His  pupils 
which  were  noted  as  reacting  normally  on  admission,  were  noted  as 
irregular  and  slow  to  react  in  June. 

On  admission  to  M.  S.  H.  the  patient  was  childishly  happy,  affable, 
loquacious,  amused  by  details,  frequently  laughing  without  much  provo- 
cation.    He  had  no  grounds  for  his  euphoria,  admitted  that  he  had  "  not  a 

5 


50  THE   DIAGNOSIS   OF   GENERAL   PARALYSIS 

d-d  cent,"  and  as  to  his  physical  condition  he  said,  "  It's  a  terrible  plight, 
I  don't  suppose  I  will  ever  get  well  again  " ;  he  laughed  cheerfully  at  the 
position. 

He  knew  he  was  in  Manhattan  State  Hospital  on  Ward's  Island,  gave 
the  date  correctly.  He  complained  spontaneously  of  his  memory  being 
poor,  and  in  giving  his  history  he  made  several  careless  mistakes;  these, 
however,  he  was  able  to  correct ;  e.  g.,  left  school  at  i6,  was  in  lawyer's 
office  for  five  years,  then  set  up  in  practice  at  23.  He  said  that  he  had 
been  ten  years  in  New  York,  had  been  working  twelve  years  for  a  New 
York  newspaper;  he  corrected  himself  when  the  discrepancy  was  referred 
to. 

He  had  a  fair  memory  for  the  period  since  his  first  attack  in  1901, 
although  he  said  that  the  interval  between  the  two  admissions  to  the 
first  hospital  was  18  months  (it  was  6).  Although  his  retention  of  a 
test  name  and  number  was  good,  he  was  very  much  confused  over  the 
incidents  of  the  immediate  past.  On  the  day  of  admission  he  thought  that 
he  had  been  two  nights  on  the  island,  and  shortly  after  admission  he 
confused  M.  S.  H.  with  B.  H.,  thought  he  had  been  there  several  months, 
said  that  the  ward  physician  had  vaccinated  him  at  B.  H. ;  and  fabricated 
an  incident  of  calling  on  the  same  physician  at  B.  H. ;  he  was  confused 
as  to  the  time  of  day;  in  the  evening  he  said  "I  thought  it  was  about 
eleven  o'clock,  I  remember  now  I  had  dinner."  He  had  some  difficulty 
in  giving  simple  facts ;  the  name  of  the  river  Hudson,  of  the  governor, 
etc.,  would  escape  him ;  the  cause  of  the  war  with  Spain  was  some  diffi- 
culty over  the  tariff. 

The  patient  admitted  that  he  had  a  bad  memory,  but  did  not  realize 
the  extent  of  his  mental  impairment,  nor  that  his  mood  was  at  all  ab- 
normal. He  had  no  absurd  ideas,  admitted  having  had  a  delirious  episode 
and   hallucinations    at    B.    H. 

Physically  he  had  the  well-marked  residuals  of  a  left-sided  hemiplegia — 
left  knee-jerk  more  exaggerated  than  the  right,  left  ankle  clonus  and 
Babinski  reflex,  weakness  of  left  arm  and  leg,  none  of  the  face.  The 
patient  was  clumsy  in  all  movements ;  in  walking  he  not  only  dragged  the 
left  leg,  but  he  walked  with  a  broad  base  of  support,  staggered  from  side 
to  side.  His  difficulty  in  maintaining  the  erect  position  was  increased 
on  closing  the  eyes.  There  was  tremor  of  the  muscles  of  the  face  and 
of  the  hands ;  his  speech  was  tremulous  and  sticking,  but  without  trans- 
position of  syllables  or  distortion  of  the  words.  His  writing  was  ex- 
tremely tremulous,  the  words  were  crowded  up  into  one  corner  of  the 
paper,  but  were  correctly  written.  The  pupils  were  dilated,  equal,  irregu- 
lar; they  reacted  well  to  light  and  on  accommodation,  also  consensually. 
The  radial  arteries  showed  no  marked  thickening. 

On  August  14,  after  ten  days  in  hospital,  the  patient  had  a  series  of 
convulsions  in  which  the  right  side  twitched  more  than  the  left ;  the  con- 
vulsions left  him  with  marked  aphasic  symptoms,  paraphasic  utterances 
and  perseveration,  and  with  weakness  of  the  right  arm,  but  without  sign 
of  Babinski  on  the  right  side.     The  pupils  reacted  very  slightly  to  light. 


THE   DIAGNOSIS   OF   GENERAL    PARALYSIS  5 1 

The    symptoms    showed    variable   intensity    for   the   next    week,    and    the 
patient  died  on  August  26,  three  weeks  after  admission. 

The  diagnosis  during  the  Hfe  of  the  patient  was  rather  doubtful, 
and  previous  to  admission  he  had  been  treated  as  a  case  of  brain 
syphiHs.  In  the  mental  status  one  of  the  most  important  features 
was  the  presence  of  a  striking  anomaly  of  mood.  The  first 
patient  made  light  of  his  bodily  condition,  talked  of  it  as  of  no 
importance,  and  his  optimism  as  to  the  future  and  as  to  his  ability 
to  work  was  evidence  of  impaired  judgment.  The  second  patient, 
on  the  contrary,  recognized  his  bodily  impairment — "  It's  a  ter- 
rible plight,  I  don't  suppose  I  will  ever  get  well  again  " — but  this 
intellectual  recognition  of  his  plight  had  no  counterpart  in  his 
mood;  he  felt  in  the  best  of  spirits,  was  not  at  all  depressed, 
laughed  cheerfully  even  when  his  condition  was  discussed,  talked 
of  inviting  some  friends  to  come  up  and  take  him  for  a  drive. 
Wernicke  has  emphasized  the  importance,  as  a  sign  of  general 
paralysis,  of  any  tendency  on  the  part  of  a  patient  to  minimize 
physical  impairment ;  it  may,  however,  be  well-marked  in  non- 
paralytic dementia.  On  the  other  hand  this  definite  primary 
euphoria,  not  associated  with  underestimation  of  the  physical  im- 
pairment, seemed  to  point  very  strongly  to  a  paralytic  process. 

The  euphoria  here  was  accompanied  neither  by  underestimation 
of  the  physical  impairment,  by  delusions  of  grandeur  of  any  de- 
scription, nor  by  any  grandiose  plans  for  future  work. 

The  patient's  memory  of  the  recent  past  showed  a  partial  reten- 
tion of  the  incidents  with  complete  confusion  as  to  their  actual 
sequence  and  relation,  and  with  a  tendency  to  fabricate ;  such  a 
confused  account,  in  a  patient  who  is  alert  and  cooperating  well, 
is  to  be  distinguished  from  the  inconsistent  and  confused  answers 
of  a  torpid  patient  giving  poor  cooperation. 

The  euphoria  and  particular  memory  defect,  in  association  with 
the  patient's  alert  attitude  during  examination,  did  not  seem  to  be 
adequately  explained  by  any  form  of  cerebral  syphilis,  but  pointed 
to  a  general  paralytic  process.  The  physical  symptom-complex 
with  the  marked  ataxia,  difficulty  in  maintaining  the  upright  posi- 
tion increased  on  closure  of  the  eyes,  marked  jerky  tremor  of  the 
hands  and  face  with  tremulous  and  sticking  speech,  seemed  also 
to  be  explained  only  on  the  basis  of  general  paralysis ;  the  ataxia 
and  the  degree  of  the  tremor  were  the  symptoms  upon   which 


52  THE   DIAGNOSIS   OF   GENERAL   PARALYSIS 

special  weight  was  laid.  The  varied  nature  of  the  neurological 
symptoms — diplopia  in  1901,  two  left-sided  hemiplegic  attacks  in 
1902,  the  latter  with  inability  to  speak  for  four  hours  although 
conscious,  the  final  convulsions  with  irritative  symptoms  on  the 
right  side  followed  by  paralytic  symptoms  on  the  same  side,  and 
by  an  aphasic  disorder — and  the  frequent  headache  during  the 
course  of  the  disease  suggested  brain  syphilis,  but  did  not  exclude 
general  paralysis ;  the  negative  result  of  treatment  pointed  to  the 
latter. 

On  the  above  grounds  it  was  felt  that  one  was  here  justified  in 
diagnosing  general  paralysis. 

The  brain  showed  distinct  cortical  atrophy  over  the  frontal 
region  on  both  sides,  with  well-marked  ependymal  granulations. 
The  cortex  showed  the  typical  changes  of  general  paralysis  with  a 
very  pronounced  perivascular  infiltrate.  In  addition  there  was  a 
cortical  softening  in  the  right  second  frontal  convolution  and  an 
old  focus  of  softening  in  the  head  of  the  caudate  nucleus  involving 
the  internal  capsule. 

In  the  two  cases  analyzed  the  attitude  of  the  patient  towards  his 
physical  disorder  and  the  nature  of  the  memory  defect  have  been 
discussed  in  some  detail.  It  may  be  useful  at  this  stage,  for  the 
sake  of  differentiation,  to  give  a  brief  summary  of  a  patient  who 
for  years  was  regarded  as  a  case  of  general  paralysis,  but  on  closer 
consideration  was  found  to  be  a  case  of  organic  dementia  on  the 
basis  of  vascular  brain-disease  and  alcoholism. 

Case  3. — Cuma  G.,  aged  39;  admitted  January  11,  1901. 

The  patient  is  a  Frenchman,  right-handed,  born  1862,  of  extremely 
alcoholic  habits  with  a  history  of  syphilis  at  20  without  medical  treatment. 
After  a  trauma  in  1890  he  was  more  susceptible  to  alcohol  than  previously. 
For  years  before  admission  he  treated  his  wife  outrageously,  did  no 
work,  drank  at  home.  In  1899  he  had  an  apoplectiform  attack,  leaving  a 
left-sided  hemiplegia ;  for  five  days  he  could  not  speak,  his  words  gradually 
came  back,  but  his  speech  remained  seriously  impaired.  (The  record  at 
the  French  Hospital  has  been  lost.)  He  was  rather  violent  and  abusive 
in  the  hospital ;  he  was  taken  home  after  two  weeks,  continued  to  show 
the  same  behavior  as  before,  was  admitted  to  M.  S.  H.  in  igoi.  The 
diagnosis  of  general  paralysis  was  made  on  an  insufficient  basis;  the 
difficulty  of  language  and  the  defective  articulation  created  the  impression 
of  a  deeper  dementia  than  really  existed,  and  this  impression  was  fostered 
by  his  rather  fatuous  chuckle. 

The  patient  has  at  the  present  date    (November,   1906),  the  residuals 


THE   DIAGNOSIS   OF   GENERAL   PARALYSIS  53 

of  a  left-sided  hemiplegia;  his  speech  is  almost  unintelligible  and  pre- 
sents the  characteristics  of  a  pseudo-bulbar  disorder.  The  pupils  react 
well.  His  mood  is  one  of  mild  discontent  with  detention,  but  during 
conversation  he  is  usually  good-natured,  chuckles  over  references  to  his 
past.  The  special  points  for  which  I  bring  the  case  forward  are  the 
defect  of  insight  which  the  patient  shows  and  the  nature  of  his  memory 
defect.  He  appears  a  little  surprised  when  the  physician  tells  him  that 
he  is  almost  unintelligible,  and  that  his  gait  is  impaired  and  that  he 
could  not  get  work;  he  grins,  says  that  he  is  all  right  and  that  he  can 
again  get  a  place  as  glass-polisher  and  earn  eighteen  dollars  a  week. 

The  second  point  is  the  memory  defect  of  the  alcoholic  and  hemi- 
plegic  Frenchman.  His  memory  is  seriously  impaired;  at  one  time  he 
says  he  was  married  in  the  City  Hall,  New  York,  then  again  that  he 
was  married  in  France.  He  says  that  he  was  already  at  work  during  the 
Franco- Prussian  war;  as  a  matter  of  fact  he  was  not  ten  at  the  time 
He  gives  the  ages  of  his  children  incorrectely.  He  gives  his  age  as  49 — 
it  is  44;  the  present  year  is  1889.  When  one  tests  his  memory,  he  re- 
peatedly answers  "  I  don't  know ;  I  can't  tell,"  seems  to  make  no  effort 
to  remember;  if  one  answer  contradict  the  previous  one,  he  is  not  em- 
barrassed, makes  no  attempt  to  reconcile  the  two  statements ;  he  does  not 
fumble  around  with  numbers;  the  test  has  no  interest  for  him,  he  needs 
repeatedly  to  be  urged  before  he  will  give  a  precise  number.  This  in- 
difference to  the  test,  the  careless  answers  when  much  urged,  the  refusal 
to  try  and  reconcile  contradictory  statements,  form  a  different  reaction 
from  the  marked  fumbling  with  dates  and  unsuccessful  endeavor  to  hold  a 
series  of  correct  data  together,  which  the  typical  general  paralytic  shows.* 

The  discussion  of  these  three  cases  has  given  rather  a  negative 
than  a  positive  result,  and  suggests  caution  in  the  use  of  certain 
defect  symptoms  as  differential  points. 

In  the  next  two  cases  the  mental  defect  symptoms  are  less 
marked  and  more  difficult  to  use,  and  it  is  on  more  transient  fea- 
tures in  the  mental  picture  and  on  the  physical  symptoms  that 
the  diagnosis  rests. 

The  cases  have  not  yet  come  to  autopsy ;  perhaps  some  may  hold 
that  the  diagnosis  has  not  been  established.  (January,  191 1.  The 
second  patient,  J.  W.  G.,  remains  practically  in  the  same  condition 
as  when  this  paper  was  read  and  this  want  of  progression  of  the 
symptoms  makes  the  diagnosis  still  more  problematical.     The  pa- 

*The  patient  died  suddenly  on  May  8,  1911,  the  neurological  symptoms 
having  shown  little  damage.  The  brain  showed  many  foci  of  softening, 
involving  the  white  matter  and  the  basal  nuclei ;  there  was  no  evidence  of 
general  paralysis. 


54 


THE   DIAGNOSIS   OF   GENERAL   PARALYSIS 


tient  J.  A.  S.  has  shown  little  physical  change,  while  an  expansive 
trend  has  become  rather  more  prominent.) 

Case  4.— James  A.  S.,  47.  admitted  April  25,  1905. 
The  patient  was  from  his  earliest  years  accustomed  to  take  alcohol, 
and  ever  since  his  marriage  in  1885  he  has  drunk  to  excess,  treated  his 
wife  outrageously,  gone  with  other  women,  spent  most  of  his  money  on 
the  race-track.  He  was  a  very  efficient  book-keeper,  and  notwithstanding 
his  drunken  habits  he  was  earning  $25  a  week  at  the  time  of  his  hemi- 
plegic  attack  in   1900. 

When  a  youth  of  16  or  17,  he  had  a  soft  sore  which  healed  in  six 
weeks ;  he  had  no  secondaries  and  a  doctor  said  that  it  was  not  syphilis. 

In  1899  he  one  day  came  home,  said  that  he  had  lost  himself  and 
could  not  remember  where  he  lived ;  there  was  no  marked  local  weakness, 
but  both  he  and  his  wife  noticed  that  one  pupil  was  larger  than  the 
other.  The  doctor  diagnosed  a  slight  stroke  of  paralysis.  During  the  next 
year  he  had  several  transitory  attacks  of  dizziness. 

In  1900,  while  he  was  dressing,  one  leg  became  weak,  he  fainted.  He 
had  a  left-sided  hemiplegia,  affecting  the  face  and  extremities.  For  a 
week  or  more  he  had  great  difficulty  in  talking,  but  understood  what  was 
said,  knew  what  he  wanted. 

For  two  or  three  months  he  continued  his  work,  but  was  very  in- 
efficient and  was  discharged;  he  was  not  drinking  as  it  made  him  very 
nervous,  nor  smoking  as  he  could  not  hold  a  cigar  in  his  mouth.  During 
the  next  two  years  he  had  occasional  positions,  but  was  usually  dis- 
charged ;  he  was  unable  to  add  up  simple  bills. 

He  continued  to  spend  all  his  money  on  horses,  none  on  his  wife  and 
children ;  he  once  came  back  from  a  position  much  excited,  said  that  he 
had  nearly  made  a  million,  that  he  received  tips  direct  from  God;  he 
frequently  made  the  latter  assertion. 

His  domestic  behavior  became  more  outrageous  and  indecent;  he  occa- 
sionally left  his  wife;  he  would  make  silly  remarks,  e.  g.,  tell  his  wife 
to  dress  up  in  gauze  and  waltz  round.  Although  limping  badly  and  stag- 
gering so  that  he  seemed  about  to  fall,  he  maintained  that  he  was  all 
right. 

In  1903  he  gradually  became  completely  deaf  in  both  ears.  Owing  to 
his  dilapidated  behavior  he  was  finally  certified  as  insane. 

During  the  eighteen  months  spent  in  the  hospital  the  patient  has 
shown  no  change.  According  to  his  wife  he  was  always  an  accom- 
plished liar,  and  in  hospital  the  patient  tells  a  plausible  story,  admitting 
his  alcoholic  and  gambling  propensities,  but  denying  that  he  ever  talked  of 
receiving  tips  from  God,  that  he  talked  of  making  a  million  or  that 
he  ever  behaved  outrageously.  He  gives  a  good  chronological  account 
of  his  life  with  exact  dates  and  no  discrepancies.  He  converses 
rationally  (the  physician  has  to  write  his  questions),  takes  an  interest  in 
the  daily  papers,  remembers  incidents  well,  has  a  fair  grasp  of  current 
events,  and  ordinary  information  ;  he  adds  promptly,  calculates  the  equiva- 
lent in  British  coinage  of  $385  with  only  a  slight  mistake. 


THE   DIAGNOSIS   OF   GENERAL   PARALYSIS  55 

Physically,  he  is  a  well-built  man,  48  years  of  age,  with  exaggeration 
of  all  the  deep  reflexes  and  residuals  of  the  left-sided  hemiplegia  attack 
in  1901 — weakness  of  the  left  side,  left-sided  ankle  clonus,  double  Babinski, 
no  dulling  of  sensibility  on  the  left  side.  In  addition  to  the  mowing  gait 
of  the  hemiplegic  he  is  markedly  ataxic;  closing  the  eyes  increases  his 
unsteadiness  in  the  upright  position.  The  pupils  are  unequal,  irregular; 
the  right  is  Argyll  Robertson,  the  left  reacts  rather  sluggishly  to  light. 
The  speech  is  loud  and  slurring,  but  not  sticking  nor  tremulous.  His 
writing  is  on  the  whole  good,  but  there  is  occasional  untidiness,  omission 
and  repetition  of  a  word  or  letter  or  mistake  with  a  syllable,  e.  g., 
Epis/'ocal,  charterwz^,  resigcnd,  practi//3>.  He  cannot  name  the  test  solu- 
tions, but  smells  equally  well  on  the  two  sides.  He  occasionally  hears  a 
very  loud  command ;  he  hears  several  noises  on  the  ward.  There  is  a 
well-marked    lymphocytosis    of    the    cerebrospinal    fluid. 

In  this  case,  as  in  the  first,  the  development  of  the  disease  was  masked 
by  alcoholism,  and  the  patient  still  has  the  attitude  of  a  plausible  alcoholic 
liar.  This  somewhat  complicates  the  estimation  of  his  insight.  He  wishes 
to  go  out,  says  that  he  wishes  to  work  for  his  wife,  and  that  old 
employers  may  help  him  to  get  some  position.  While  he  recognizes  his 
deafness  and  the  presence  of  weakness  on  the  left  side,  he  does  not 
admit  any  mental  impairment  nor  have  an  adequate  idea  of  his  physical 
condition;  his  wife  had  been  struck  by  his  refusal  to  admit  that  there 
was  anything  the  matter  with  him. 

The  patient's  marked  alcoholism  accounts  in  part  for  his  abnormal 
behavior  before  admission,  but  not  for  several  factors — ^the  absolute  loss 
of  the  sense  of  decency  (the  patient  would  defecate  on  a  chair  instead 
of  going  to  the  toilet;  he  would,  when  apparently  sober,  sexually  assault 
his  wife  in  presence  of  the  children),  the  childish  behavior  (e.  g.,  he 
would  throw  into  the  box  a  letter  with  a  farewell  message  to  his  wife, 
and  would  then  run  away),  his  receiving  tips  from  God  and  talk  of 
making  millions  (at  this  time  he  was  not  drinking  hard).  This  behavior 
had  a  peculiar  stamp  of  dilapidation ;  it  is  met  with  in  general  paralysis, 
and  I  do  not  know  if  cases  of  brain  syphilis  may  present  it. 

Mentally,  then,  the  important  differential  points  in  this  case  are 
the  special  form  of  dilapidated  conduct,  the  inadequate  realization 
of  his  condition,  the  psychotic  symptoms,  and  the  mistakes  in 
writing.  The  condition  of  the  pupils  may  be  met  with  in  brain 
syphilis;  as  to  the  value  of  the  ataxia  with  definite  sign  of  Rom- 
berg as  a  differential  point  between  general  paralysis  and  the  vari- 
ous forms  of  brain  syphilis,  I  have  no  data. 

Case  5.— Joseph  W.  G.,  38,  admitted  July  30,   1901. 

The  patient  was  born  in  1864  in  New  York  city,  developed  normally 
and  worked  at  a  variety  of  occupations;  he  is  not  known  to  have  taken 
alcohol  to  excess.     In   1890  he  had  a  sore  on  his  penis,  and  took  internal 


56  THE  DIAGNOSIS   OF   GENERAL   PARALYSIS 

medicine  for  one  month;  in  1894  he  began  to  suffer  from  pains  in  the 
back  and  chest,  accompanied  by  nausea  and  vomiting;  for  the  next  six 
years  he  continued  to  have  episodes  of  lancinating  pains  at  intervals  of 
two  and  three  weeks ;  in  1900  he  was  diagnosed  incipient  locomotor  ataxia ; 
the  pupils  were  Argyll  Robertson,  the  knee  jerks  diminished. 

For  a  few  months  before  commitment  in  1901,  he  had  grandiose  plans 
for  working  a  patent,  he  talked  a  great  deal  about  money,  and,  when 
committed,  he  was  talkative,  elated,  and  expansive;  he  said  that  he  was 
worth  $90,000,  the  patent  was  worth  $35,000,000. 

After  a  few  months,  this  trend  simmered  down  and  the  patient  became 
slightly  depressed ;  one  year  after  admission,  he  had  much  improved  and 
possessed  considerable  insight  into  his  past  condition. 

He  had  later  a  depressed  period,  then  in  1904  was  megalomanic. 

Neurological  Incidents. — The  patient  had  already  in  1898  had  a  transi- 
tory weakness  of  his  left  side  with  paraesthesia,  of  half  an  hour's  dura- 
tion; in  1903,  he  had  an  attack  of  unconsciousness  followed  by  con- 
fusion; in  1904  he  had  a  sudden  apoplectiform  attack,  leaving  a  perma- 
nent left-sided  hemiplegia  with  marked  impairment  of  sensibility  on  the 
left  side,  and  with  left-sided  hemianopia. 

Present  Condition,  November,  1906. — The  patient  has,  for  at  least  a 
year,  shown  practically  the  same  condition ;  he  is  quite  clear,  knows  all 
the  hospital  gossip,  takes  an  interest  in  the  papers,  wishes  to  go  home;  he 
admits  that  he  had  temporary  insanity  on  admission,  sometimes  he  says 
that  it  was  the  commitment  which  made  him  insane;  he  says  that  he  was 
funny,  had  strange  ideas  in  1901 ;  he  attributes  his  megalomanic  attack  in 
1904  to  being  tormented  by  other  patients.  He  misinterprets  various 
paraesthesias  as  due  to  electricity  and  magnetism,  and  frequently  shouts 
out  loudly  at  night  owing  to  this  torment ;  when  questioned  on  the 
subject,  he  is  evasive,  at  first  merely  talks  of  an  uncomfortable  mattress, 
then  admits  that  the  feelings  must  be  due  to  electricity,  etc. ;  there  is 
little  attempt  to  elaborate  the  subject.  He  says  that  he  is  constipated; 
when  urged,  he  makes  hypochondriacal  statements  as  to  his  abdomen,  his 
stomach  is  all  cut  out,  he  is  ruined,  he  is  only  a  shell,  the  attendants 
during  his  crazy  spell  in  1904  cut  his  stomach  out  with  poison. 

The  patient  has  an  excellent  memory,  both  for  the  recent  and  the 
remote  past,  he  has  a  detailed  grasp  of  his  various  transfers  in  the  hospital 
and  of  the  dates  of  minor  events ;  there  is  no  discrepancy  in  his  dates. 

Physically,  the  patient  shows  the  residuals  of  a  left-sided  hemiplegia; 
there  is  little  weakness,  but  there  is  Babinski  reflex  on  the  left  side, 
hemiplegic  gait  with  the  arm  in  the  wing  position,  the  sensibility  much 
more  impaired  on  the  left  than  on  the  right  side;  left-sided  hemianopia; 
there  is  marked  ataxia  of  left  arm  and  leg;  the  difficulty  in  maintaining 
the  upright  position  is  not  increased  on  closing  the  eyes;  the  knee  jerks, 
which  were  diminished  in  1901,  are  now  definitely  exaggerated;  the 
pupils  are  equal,  irregular,  Argyll  Robertson.  Writing  tremulous  with 
distorted   words.     Speech   tremulous. 

The  patient  realizes  his  physical   impairment,   he  attributes   it  to  his 


THE   DIAGNOSIS   OF   GENERAL   PARALYSIS  5/ 

treatment  in  the  hospital,  misinterprets  his  abnormal  sensations;  he  is 
anxious  to  go  home  and  help  his  mother,  says  that  he  can  get  a  job  as 
night-watchman,  in  some  places  the  watchman  needs  only  to  sit  behind 
the  door  all  night,  he  could  make  money  as  an  entertainer  as  he  is  full 
of  jokes,  he  could  write  a  book  of  experiences,  and  would  easily  find  a 
publisher. 

This  self-confidence  is  based  rather  on  a  want  of  judgment  of  the 
ordinary  relations  of  life  than  on  a  failure  to  recognize  his  own  general 
condition;  it  is  the  same  symptom,  though  in  less  degree,  as  his  original 
grandiose  plans  to  develop  a  patent. 

He  admits  that  he  is  physically  weak  and  that  he  is  even  slightly 
touched  in  the  head;  fresh  air  and  city  doctors  will  soon  cure  him. 

The  patient's  want  of  judgment  is  seen  in  another  point;  he  fre- 
quently sits  and  loudly  talks  of  the  injustice  of  his  detention;  when 
interviewed,  he  frequently  repeats  his  grievances,  but  he  does  so  more 
apparently  to  give  vent  to  his  feelings  than  with  any  hope  of  changing 
the  situation. 

He  never  argues  the  point  with  the  physician,  never  asks  him  to  take 
definite  steps  for  his  discharge  nor  asks  him  for  the  grounds  of  his 
detention;  while  repeating  his  claims,  he  acquiesces  in  the  situation,  some- 
times even  laughs  at  it  and  bears  no  ill-will  for  his  detention. 

This  acquiescence  in  the  situation  in  certain  cases  of  dementia  para- 
lytica contrasts  strikingly  with  the  retained  intellectual  grasp  of  relations 
and  with  the  actual  demands  for  discharge,  which  may  be  set  aside  by 
the  physician  without  provoking  any  rerhonstrance  from  the  patient.  Be- 
sides these  defect  symptoms  the  patient  has  presented  additional  symptoms, 
megalomanic  periods,  persistent  hypochondriacal  statements,  and  false 
interpretations  of  morbid  sensations.  The  importance  of  the  former  two 
elements  in  the  diagnosis  of  general  paralysis  is  generally  emphasized: 
one  must  remember,  however,  that  in  syphilitic  meningoencephalitis  a 
megalomanic  trend  may  be  present,  and  a  hypochondriacal  element  is 
frequently  present  in  arteriosclerotic  dementia.* 

Case  6. — Mrs.  Annie  F.,  43,  admitted  March  18,  1905. 

The  patient  is  a  Russian  woman  of  low  social  status,  who  was  an 
efficient  housewife,  and  enjoyed  moderate  health  until  igo2  or  1903;  no 
history  of  syphilitic  infection  was  obtained  from  the  informants,  but  the 
patient  had  numerous  suspicious  scars  on  her  legs;  she  had  several  mis- 
carriages and  her  husband  has  suspicious  nervous  symptoms.  About 
three  years  before  admission,  she  began  to  eat  ravenously  and  to  sleep 
constantly,  she  neglected  her  housework,  was  very  apathetic,  complained 
of  frontal  headache  and  of  seeing  double.     On  one  occasion,  about  two 

*The  patient  died  on  May  28,  191 1  from  a  sub-dural  haemorrhage 
caused  by  a  fall  during  a  convulsive  seizure.  At  the  autopsy  the  brain 
presented  a  diffuse  atrophy  of  the  right  hemisphere,  but  no  definite  evi- 
dence of  general  paralysis:  microscopical  examination  disclosed  the  histo- 
pathological  changes  of  general  paralysis. 


58  THE   DIAGNOSIS   OF   GENERAL   PARALYSIS 

years  before  admission,  she  daefecated  in  bed,  then  threw  the  faeces  with 
her  hand  on  the  wall;  when  asked  what  was  the  matter,  she  said 
"nothing";  during  the  last  two  years,  she  spent  the  whole  time  sitting 
in  her  chair,  took  no  interest  in  what  went  on,  admitted  that  she  was 
weak,  but  said  that  there  was  nothing  wrong  with  her;  she  answered 
most  questions  with  "  I  don't  know,"  she  occasionally  soiled  the  bed. 
There  was  no  history  of  elation  nor  depression ;  a  vague  statement  that 
she  had  heard  voices  was  not  corroborated. 

On  admission  the  patient  was  very  placid,  had  a  never-failing  me- 
chanical smile;  she  answered  questions  pleasantly,  but  showed  little  spon- 
taneity; her  mood  was  one  of  complacent  indifference;  she  accepted  the 
environment  without  criticism;  there  was  no  elation,  no  definite  de- 
pression, but  she  felt  that  she  was  an  invalid,  emphasized  her  ailments 
with  some  hypochondriacal  zest ;  "  I  am  very  weak — I  am  nearly  blind — I 
can't  walk."  She  gave  a  strong  handgrip;  her  gait  was  shuffling,  but  not 
very  much  impaired;  she  could  count  correctly  fingers  held  up  at  ten 
feet ;  at  the  same  time  she  said  that  she  saw  double. 

The  patient  showed  a  marked  memory  defect,  which  consisted  not  so 
much  in  loss  of  memory  of  the  incidents  as  in  inability  to  space  them 
out  correctly  in  time;  successive  answers  to  the  same  questions  were 
widely  different,  e.  g.,  she  said  that  she  sailed  for  America  at  15,  19  and 
29;  with  regard  to  other  events,  she  gave  equally  inconsistent  dates. 
She  did  not  spontaneously  see  even  glaring  discrepancies ;  she  said  that 
she  was  divorced  at  23,  came  to  America  at  25,  came  to  America  in 
the  year  of  her  divorce.  She  was  an  extremely  ignorant  woman,  but 
her  calculation  was  better  than  one  would  have  expected. 

The  patient  realized  her  changed  mental  and  physical  condition ;  "  I 
am  not  clear — I  have  not  the  spirit  of  work — I  should  like  to  sleep  always 
for  the  last  two  years — my  head  is  so  slow — my  head  is  weak " ;  she 
exaggerated  rather  than  minimized  her  physical  ailments. 

Physically,  she  was  a  well-nourished  Jewess  with  fair  muscular 
force  and  no  sensory  disorder;  the  knee-jerks  were  both  exaggerated;  the 
gait  was  shuffling,  not  ataxic ;  sign  of  Romberg  was  noted  on  the  first 
examination,  but  not  on  subsequent  examinations ;  there  was  tremor  and 
jerking  of  individual  fingers;  the  speech  showed  decided  sticking  on  1 
and  r  with  tremor  of  the  facial  muscles ;  the  pupils  were  equal,  reacted 
well ;  weakness  of  left  external  rectus  and  slight  nystagmus  in  external 
fixation.  She  complained  of  a  variety  of  subjective  disorders  during  the 
previous  two  years — severe  frontal  headaches,  noises  of  whistling  and 
ringing  in  the  ears,  her  head  felt  funny,  she  was  like  drunk,  was  dizzy. 

During  the  nineteen  months  of  hospital  residence,  the  patient  has 
shown  little  variation ;  she  does  whatever  work  she  is  asked  to  do,  keeps 
track  of  the  time  and  of  the  major  incidents  in  the  ward;  during  an 
interview  she  asks  for  discharge,  but  never  pushes  the  question  nor 
spontaneously  addresses  the  physician   with   this   in  view. 

In  this  case,  as  in  the  preceding  cases,  there  was  a  dementia 


THE   DIAGNOSIS   OF   GENERAL   PARALYSIS  59 

characterized  by  an  inadequate  attitude  towards  detention  and  by 
a  striking  inability  to  see  glaring  discrepancies  in  dates ;  additional 
features  were  the  episode  at  the  onset  and  the  mild  hypochon- 
driasis. 

I  do  not  know  that  cases  of  brain  syphilis  ever  present  such  a 
form  of  dementia. 

Tabes  and  General  Paralysis. — Where  a  psychosis  is  found  to 
be  associated  with  tabes  one  is  tempted  to  immediately  conclude 
that  the  case  is  one  of  general  paralysis.  In  several  cases  reported 
in  the  literature,  where  this  was  not  done  and  a  non-paralytic 
dementia  with  tabes  had  been  diagnosed,  the  anatomical  examina- 
tion demonstrated  the  histopathological  changes  of  general  paral- 
ysis. Many  cases  have  been  published  of  non-paralytic  psychoses 
with  tabes ;  there  is  on  the  one  side  the  case  where  a  patient  with 
a  psychosis,  e.  g.,  a  manic-depressive,  gets  syphilis  and  later  de- 
velops tabes,  and,  on  the  other  side,  the  case  where  on  the  basis 
of  an  established  tabes  a  psychosis,  usually  a  paranoic  condition 
or  a  depression,  arises. 

Alzheimer  records  two  cases  where  the  dementia  was  demon- 
strated to  be  not  due  to  a  general  paralytic  process. 

In  the  following  case,  for  a  long  period  it  was  felt  that  there 
were  insufficient  grounds  for  considering  the  disorder  general 
paralysis ;  the  nature  of  the  dementia  which  later  became  estab- 
lished cleared  up  the  diagnosis. 

Case  7. — Mary  B.,  46,  admitted  February  22,  1905,  discharged  De- 
cember 24,  1905;  readmitted  May  S,  1906. 

The  patient  is  an  Irish  woman  who  has  lived  a  rather  irregular  sexual 
life,  and  whose  husband  claims  that  he  received  syphilis  from  her  in  1899; 
there  is  no  history  of  alcoholism.  On  the  death  of  her  youngest  child 
in  October,  1904,  she  was  rather  depressed,  but  seemed  to  regain  her  equi- 
librium. In  February,  1905,  she  began  to  complain  of  being  sick  and  of 
pains  in  her  legs ;  she  was  sleepless,  refused  food  and  medicine.  Two 
weeks  later  she  made  peculiar  treading  movements  with  her  legs  in  bed, 
said  she  could  not  help  it. 

For  several  days  before  admission  she  said  "  I  think  I'm  getting 
crazy."  She  told  the  ambulance  surgeon  that  worry  over  her  baby  had 
driven  her  crazy.  In  Bellevue  Hospital  she  uttered  ideas  of  fear  with 
smiling  unconcern ;  she  said  "  I  see  all  kinds  of  funny  things  when  I 
close  my  eyes,  I'm  so  light-headed  all  the  time,  I  hear  kind  of  funny 
noises  in  my  ears." 

On  admission  the  patient  was  quiet,  seemed  to  take  no  interest  in  her 


60  THE  DIAGNOSIS   OF   GENERAL   PARALYSIS 

surroundings,  showed  no  spontaneity;  she  answered  questions  in  mono- 
syllables, replied  "  I  don't  know  "  to  almost  every  question,  even  to  ques- 
tions to  which  she  had  previously  given  a  correct  answer.  Her  mood, 
when  unmolested',  was  one  of  complete  indifference,  but  when  examined 
vigorously  her  unconcern  was  replaced  by  a  look  of  dazed  perplexity 
and  some  alarm  and  agitation.  Owing  to  her  monotonous  answer  of 
"  I  don't  know,"  or  "  I  can't  tell "  to  almost  every  question,  her  memory, 
grasp  of  general  information,  etc.,  could  not  be  tested. 

Physical  Status. — Absence  of  knee-  and  Achilles-jerks,  also  of  corneal 
and  pharyngeal  reflexes;  very  slight  reaction  of  pupils  to  light,  fair  on 
accommodation ;  unsteadiness  of  gait  and  upright  position ;  no  reaction 
to  pin-pricks  except  over  the  soles  of  the  feet.  The  mouth  was  foul,  the 
tongue  dry  and  hard. 

For  two  or  three  weeks  the  patient  continued  to  give  the  same  nega- 
tive answers;  she  made  no  sign  of  recognizing  her  children.  She  said 
that  she  was  blind,  but  at  the  same  time  she  recognized  figures  and 
letters.  One  day  she  said  that  she  had  no  feeling,  no  life — "you  have  no 
idea  how  terrible  I  feel,  I  wish  I  was  dead  rather  than  in  this  way."  On 
one  occasion  she  recognized  her  children  at  first,  but  during  the  same 
interview  said  that  she  did  not  know  them;  when  asked  to  explain  this 
she  said,  "  I  could  not  see  them — I  could  not  see  them  plain." 

In  April  she  improved,  took  some  interest  in  home  affairs,  was  more 
cleanly;  for  two  weeks  she  frequently  walked  with  her  legs  crossed,  even 
when  going  up-stairs;  no  reason  was  given  for  this.  She  winced  at  pin- 
pricks, but  denied  that  she  felt  pain.  She  began  to  answer  questions  about 
the  past,  but  was  absolutely  indifferent  to  absurd  contradictions  in  her 
time  relations;  she  remembered  in  remarkable  detail  the  events  associated 
with  her  admission,  having  registered  correctly  even  the  names  of  the 
patients  who  came  with  her  from  Bellevue  Hospital  to  M.  S.  H. ;  for  a 
while  she  was  depressed  over  her  condition,  which  she  described  as  in- 
curable insanity.  Although  she  had  a  fair  grasp  of  the  environment,  she 
thought  the  city  was  "  empty  houses,"  the  people  on  the  passing  steam- 
boats were  "  make-believe." 

Her  memory  improved  so  that  she  was  able  to  give  a  fairly  accurate 
account  of  her  life.  In  December  she  was  well  enough  to  be  discharged. 
Her  plans  for  the  future  were  quite  reasonable;  she  had  good  insight  into 
her  mental  disorder,  remembered  the  various  peculiar  ideas  she  had  had. 
Physically  there  was  noted  absence  of  knee-jerks,  Argyll  Robertson  pupils, 
slight  difficulty  in  speaking  the  test  phrases;  no  tremor,  no  ataxia,  no 
sign  of  Romberg. 

In  view  of  the  close  connection  of  tabes  and  general  paralysis  the 
diagnosis  of  general  paralysis  seemed  the  most  probable  one,  but  in  view 
of  the  peculiar  nature  of  the  mental  symptoms  the  diagnosis  was  not 
considered  as  established,  nor  the  possibility  of  a  non-paralytic  tabetic 
psychosis  excluded.  The  mental  picture  had  been  that  of  a  depression, 
with  a  consciousness  of  mental  inefficiency,  which  later  passed  into  a 
peculiar  condition  of  apathy  with  negative  replies ;  when  she  improved 


THE   DIAGNOSIS   OF   GENERAL   PARALYSIS  6 1 

SO  far  as  to  give  her  history,  she  ignored  the  hopeless  discrepancies  in 
her  statements;  on  further  improvement  her  discrepancies  seemed  almost 
sufficiently  accounted  for  by  her  general  ignorance.  The  possibility  of  an 
hysterical  element  was  suggested  by  the  apparently  blank  state  of  mind, 
the  abrupt  alternation  between  recognition  and  non-recognition  of  visitors, 
the  denial  of  any  memory  of  a  visit  with  no  indication  of  an  actual  defect 
of  retention,  a  certain  suggestibility,  and  the  peculiar  gait  which  seemed 
to  arise  from  a  casual  attitude ;  the  pharyngeal  reflex  was  absent,  the 
corneal  much  diminished,  there  was  almost  general  analgesia. 

The  diagnosis  was  therefore  not  considered  to  be  established. 

The  patient  was  discharged  on  Christmas  Eve,  1905,  and  appeared 
to  be  in  good  mental  health,  but  after  about  one  month  she  began  to  show 
marked  lapses  in  conduct;  she  would  go  about  the  house  practically  naked, 
she  wandered  away  from  home  for  days  at  a  time;  she  was,  therefore, 
readmitted  May  5,   1906. 

On  re-admission  the  patient  recognized  all  her  old  acquaintances,  said 
that  she  was  glad  to  be  back,  talked  of  her  sickness  with  cheerful  in- 
difference, gossiped  pleasantly  about  the  past.  She  described  in  a  matter- 
of-fact  way  an  episode  when  she  had  rambled  away  from  home  and  spent 
two  days  in  the  park :  "  I  don't  know  why  I  stayed-^I  guess  I  was  too 
lazy  to  walk  home."  She  compared  herself  jocularly  to  an  actor  out  of 
work.  She  admitted  that  this  was  crazy  behavior,  saying  "  sure,  I  was 
off  my  trolley  again,"  but  again  said  that  she  was  not  crazy. 

She  had  a  good  memory  for  the  incidents  of  the  past,  but  showed 
absolute  inability  to  grasp  glaring  discrepancies  in  her  dates ;  she  said 
"this  is  1896,"  and  that  she  had  her  last  baby  July  4,  1896. 

Her  conduct  in  the  ward  was  rather  dilapidated;  she  was  very  un- 
cleanly, at  night  pulled  at  the  other  patients'  clothes  as  she  wanted  to 
go  home ;  she  pinned  bed  lineni  under  her  own  clothes.  The  garrulous 
talk  of  the  patient  was  of  a  drifting  flighty  character,  e.  g.,  "  Do  you 
know  my  sister  Nellie  is  dead,  God  is  slow  but  he's  sure,  we  all  have  to 
go  some  day,  how  is  it  the  Chinese  get  something  to  eat  in  the  coffin,  they 
wake  up  and  have  something  to  eat  (laughs),  the  Jews  put  in  a  quarter, 
she  was  buried  in  Evergreen  with  her  husband,"  etc. 

She  commented  on  passing  boats  and  on  remarks  of  other  patients. 

Her  writing  was  much  worse  than  during  the  previous  admission,  the 
words  being  distorted  into  a  series  of  meaningless  characters. 

After  about  a  month  the  patient  had  given  up  her  pranks,  was  cleanly 
and  a  useful  worker,  and  since  that  time  she  has  continued  to  maintain 
the  same  level  of  a  mild  dementia.  She  knows  all  the  hospital  gossip, 
enjoys  life  in  the  ward  but  talks  of  returning  home  again ;  her  future 
plans  are  quite  reasonable.  She  still  shows  absurd  discrepancies  in  her 
dates,  e.  g.,  married  in  1885,  born  in  1896.  She  admits  that  she  was 
crazy  on  her  first  admission,  but  not  on  the  second;  she  was  only  brought 
here  because  she  went  to  the  park. 

The  following  are  the  important  features  in  her  dementia — the 


62  THE   DIAGNOSIS   OF   GENERAL    PARALYSIS 

contentment  with  hospital  life  as  satisfying  most  of  her  aspi- 
rations, the  imcritical  attitude  towards  the  wandering  episodes  and 
past  behavior,  the  absurdly  contradictory  dates,  the  extreme  dis- 
tortion of  written  words ;  such  a  dementia  presents  the  features 
which  in  the  preceding  cases  were  emphasized  as  of  differential 
importance,  and  in  conjunction  with  tabes  warrants  the  diagnosis 
of  dementia  paralytica. 

From  the  above  observations  it  would  seem  that  for  clinical 
differentiation  a  study  of  the  dementia  itself  is  important.  The 
dementia,  however,  was  not  the  only  element  present  in  the  cases ; 
other  features  were  also  present,  either  behavior  with  a  peculiar 
stamp  of  dilapidation,  or  psychotic  symptoms,  which  form  the 
"  crazy  "  element  in  the  picture. 

The  limits  of  this  communication  do  not  permit  a  discussion  of 
these  latter  symptoms,  but  it  is  sometimes  on  these  latter  symp- 
toms that  our  diagnosis  frequently  rests ;  the  diagnosis  may  be 
established  before  the  presence  of  any  dementia  can  be  demon- 
strated ;  no  defect  may  be  observed  save  the  absence  of  the  pa- 
tient's critical  faculty  in  face  of  his  own  grandiose  plans. 

This  was  the  case  in  the  following  observation. 

Case  8.— The  patient  (Emil  K.),  admitted  January  13,  1906,  age  35, 
an  alcoholic  bartender,  became  restless  and  irritable  shortly  before  ad- 
mission, was  unable  to  do  his  work,  formed  great  plans  for  making  money, 
was  sent  to  the  hospital.  When  admitted  to  the  hospital  he  was  restless, 
excited,  talkative,  harped  on  his  grandiose  schemes :  he  intended  to  marry 
a  beautiful  girl,  would  call  on  the  Emperor,  etc.  He  showed  absolutely 
no  memory  defect,  was  clear  in  his  orientation.  His  restlessness  quickly 
disappeared,  the  expansive  trend  simmered  down,  and  two  months  after 
admission  there  was  no  trace  of  the  psychosis,  except  a  slight  tendency 
to  minimize  the  absurdity  of  his  crazy  ideas  on  admission. 

He  was  discharged  four  months  after  admission  apparently  in  excellent 
mental  health,  took  up  a  position  and  earned  fair  wages. 

His  physical  status  presented  the  same  neurological  complex  during 
his  whole  stay  in  the  hospital — exaggeration  of  deep  reflexes,  unequal 
pupils  reacting  sluggishly  to  light,  tremor  of  fingers  and  tongue,  marked 
lymphocytosis  of  the  cerebrospinal  fluid;  no  defect  in  speech,  writing  nor 
gait. 

Here,  then,  was  a  fairly  pure  megalomanic  episode  without  any  of  the 
defect  symptoms  described  above.  The  diag^nosis,  however,  did  not 
seem  open  to  doubt. 

In  such  a  case  the  presence  of  a  well  marked  lymphocytosis  is  a 
source  of   comfort  to  the  clinical   observer. 


THE  DIAGNOSIS   OF   GENERAL   PARALYSIS  63 

The  last  case  which  I  wish  to  report  is  that  of  a  patient  observed 
by  Dr.  Meyer,  where  the  possibiHty  of  brain  tumor  was  seriously 
considered,  but  which  turned  out  to  be  an  atypical  general 
paralysis. 

Case  9. — The  patient  was  born  in  1857,  at  the  age  of  23  had  some 
venereal  infection,  when  42  complained  of  unsteadiness  and  weakness  of 
the  left  hand ;  he  became  fatigued,  unable  to  do  his  work ;  his  gait 
became  unsteady,  with  weakness  of  the  left  leg.  After  three  months' 
vacation  he  became  slightly  expansive,  irritable,  and  showed  a  childish 
behavior. 

January  17,  1900,  twitching  of  the  left  arm,  anesthesia  of  the  left  arm, 
reduction  of  muscular  sense  and  attention  to  motility  on  the  left  side, 
exaggerated  tendon  reflexes  on  the  left  side.  The  anaesthesia  spread 
later  to  the  trunk  and  the  left  leg;  Babinski  reflex  developed  on  the  left 
side.  In  October  the  patient  had  an  attack  of  left-sided  twitching;  after 
this,  left-sided  hemianopia  was  noted.  The  left  pupil  was  larger  and 
more  sluggish  than  the  right.     The  left  side  became  more  rigid. 

As  to  the  mental  symptoms  the  patient  had  been  euphoric  and  talka- 
tive at  first,  with  good  orientation,  fair  memory,  but  defective  calculation. 
In  summer  he  became  dull,  careless  and  untidy.  In  November  he  fabri- 
cated; he  later  became  duller  and  less  responsive.     He  died  May,  1901. 

As  to  the  diagnosis,  the  optic  discs  were  normal,  there  was  no  history 
of  headache,  vomiting  nor  dizziness,  but  both  the  irritative  and  the  para- 
lytic symptoms  with  their  steady  progression  suggested  the  possibility  of  a 
tumor.  The  mental  symptoms  suggested  strongly  general  paralysis,  but 
were  not  inconsistent  with  brain  tumor. 

On  post-mortem  examination  it  was  found  to  be  a  case  of  atypical 
general  paralysis,  the  process  being  of  exceptional  severity  over  the 
posterior  half  of  the  right  hemisphere.  In  some  parts  of  this  region 
there  was  complete  disappearance  of  the  nerve  cells;  the  vessel  changes 
were  well  marked,  the  perivascular  infiltrate  moderate.  On  the  right 
side  the  pulvinar  was  much  affected.  In  addition  to  the  severe  affection 
of  the  right  parietal  and  occipital  lobes  there  was  present  a  correspond- 
ing atrophy  of   the   left  cerebellar  hemisphere. 


CLINICAL  VARIETIES  OF  PERIODIC  DRINKING^ 
By  Pearce  Bailey,  M.D., 


NEW   YORK 


Singled  out  and  separate  from  habitual  drinking  is  a  type  of 
alcoholism  characterized  by  its  periodicity.  There  are  recurring 
attacks  of  intemperance  and  debauch,  lasting  from  a  few  days  to 
several  weeks.  Between  the  attacks  the  subjects  are  either  tem- 
perate or  abstemious,  or  have  a  distinct  distaste  for  liquor,  and, 
for  the  first  few  years  at  least,  bear  none  of  the  physical  or  mental 
stigmata  of  alcoholism.  The  periodic  character  of  this  variety  of 
inebriety  has  long  caused  it  to  be  compared  with  another  par- 
oxysmal disease,  epilepsy.  And  since  Gaupp,  in  a  carefully  pre- 
pared monograph  on  dipsomania,  published  in  i9oi,drew  the  lines 
closely  together  from  cases  of  his  own  and  from  literature,  there 
has  been  a  gradually  growing  conviction  that  dipsomania  is  one 
of  the  larval  forms  of  epilepsy.  It  cannot  be  denied  that  there 
are  striking  points  of  similarity  between  typical  cases  of  dipso- 
mania and  epilepsy.  Many  dipsomaniacs  have  had  convulsions 
and  in  nearly  all  of  them  may  be  found  the  same  neuropathic 
antecedents  as  are  met  with  in  the  histories  of  epileptics.  Again, 
the  action  of  alcohol  upon  a  diseased  or  intolerant  brain  recalls 
in  many  ways  certain  symptoms  of  epilepsy.  Intolerance  to  alco- 
hol, to  the  results  of  which  the  Germans  have  given  the  name 
pathological  drunkenness,  is  essentially  epileptic  in  character.  In 
it,  after  the  ingestion  of  very  small  quantities  of  spirits  or  even 
beer,  the  individual  becomes  immediately  flushed  and  excited,  vio- 
lent and  often  dangerous  to  others.  A  similar  intolerance  is  com- 
mon in  epileptics,  and  is  particularly  liable  to  induce  states  of 
automatism  in  which  the  patient  is  no  longer  responsible.  It  is 
also  frequent  in  other  cortical  diseases  or  degenerations,  of  which 
it  may  be  the  earliest  diagnostic  sign.     Notable  among  the  brain 

^  Read  at  a  meeting  of  the  New  York  Psychiatrical  Society  on  May  5, 
1909.     Copyright,   William   Wood  &   Company. 

6  65 


66  CLINICAL   VARIETIES   OF    PERIODIC   DRINKING 

conditions  in  which  intolerance  is  encountered  are  general  paresis, 
degeneration  of  the  cerebral  arteries,  and  the  state  of  depressed 
cortical  function  which  often  follows  traumatic  injuries  of  the 
head. 

In  addition  to  these  general  similarities  an  attack  of  dipso- 
mania has  certain  psychic  characteristics  in  common  with  those  of 
grand  mal.  In  both  the  patient  becomes,  for  a  short  time  before 
the  attack,  restless,  anxious,  dissatisfied ;  he  reproaches  himself 
for  misconduct  which  had  long  lain  forgotten ;  and  all  this  without 
reasonable  cause.  This  premonitory  depression  is  constant  in 
true  dipsomania  and  is  becoming  more  and  more  recognized  as  a 
cardinal  symptom  of  epilepsy.  In  addition,  retrograde  amnesia, 
as  well  as  amnesia  for  parts  of  the  attack  itself,  is  common  in 
both  conditions. 

I  have  notes  of  a  case  of  a  young  man,  by  nature  temperate  and 
self -controlled,  in  whom  the  attacks  recurred  every  two  or  three 
months,  sometimes  less  frequently.  The  antecedent  depression 
was  marked,  and  readily  recognized  by  the  family.  The  seizures 
were  characterized  by  wild  intemperance,  debauch,  and  violence. 
There  were  distinct  losses  of  memory  for  parts  of  the  attack  itself, 
and  often  also  for  several  hours  preceding  the  first  drink.  The 
apparently  hopeless  outlook  in  this  case,  which  I  have  watched 
for  five  years ;  its  explosive  character  without  any  psychic  cause 
which  can  be  ascertained,  and  the  bad  family  history,  seem  to 
mark  it  definitely  as  dipsomania  of  epileptic  nature,  dependent  on 
the  same  cortical  irritation  as  causes  epilepsy.  Certain  cases  cited 
by  Gaupp  also  seem  equally  incontestable.  But  such  cases  are 
rarities. 

Perhaps  no  one  sees  so  many  varieties  of  alcoholism  in  their 
formation  period  as  a  neurologist  practising  in  a  large  city.  And 
of  the  various  cases  of  periodic  drinking  I  have  seen,  the  one  men- 
tioned is  the  only  one  in  which  epilepsy  seemed  the  only  explana- 
tion. In  the  others,  various  causal  factors  pressed  forward  for 
recognition,  equally  or  more  deserving  of  attention  than  epilepsy. 
So  I  now  believe  that  many  of  the  so-called  epileptic  dipsomanias 
can  be  better  explained  on  some  other  hypothesis ;  that  what  seem 
at  first  sight  as  epileptic  explosions  can  frequently  be  reduced  to 
certain  phases  of  mental  disease,  the  clinical  characteristics  of 


CLINICAL   VARIETIES   OF    PERIODIC   DRINKING  6/ 

which  soon  become  blurred  by  alcohol,  or  to  the  influence  of  some 
recurring  psychic  motive. 

The  importance  of  such  a  distinction  is  real,  both  for  prognosis 
and  treatment.  True  dipsomania  has  the  same  prognosis  and 
treatment  as  epilepsy.  Periodic  drinking  from  other  causes  offers 
more  hope  for  amelioration  in  that  the  cause,  when  found,  is 
more  get-at-able ;  and  the  case  as  a  whole  can  be  better  understood 
and  more  rationally  handled,  if  its  causal  factors  are  revealed. 

In  the  listed  types  of  mental  disease,  alcohol  plays  a  varying 
role.  It  is  not  conspicuous  in  dementia  praecox  or  in  melancholia. 
In  fact,  the  generally  received  belief  that  mental  depression  causes 
periodic  drinking  seems  true  only  insofar  as  it  applies  to  depres- 
sion within  the  limits  of  sanity.  Under  the  stress  of  business 
reverses,  family  troubles,  failing  health,  many  become  tipplers. 
Some  become  periodic  drinkers.  The  most  familiar  type  of  this 
is  the  emotional,  high  strung  man  who  gets  wildly  drunk,  often 
for  several  days,  after  quarrels  with  his  wife.  But  the  recurring 
attacks  of  depression  in  which  the  depression  is  out  of  sane  pro- 
portion to  the  causes  alleged  to  have  induced  it — that  is,  the 
recurring  depressive  cycles  of  a  manic-depressive  insanity,  seem 
rarely  if  ever  to  incite  to  inebriety. 

In  general  paresis  sudden  attacks  of  inebriety  are  extremely 
common,  as  is  to  be  expected  from  the  epileptic  associations  of 
this  disease.  It  is  only  when  these  attacks  precede  the  physical 
signs  or  the  mental  deterioration  that  diagnosis  is  difficult. 

In  the  manic  phases  of  a  manic-depressive  psychosis,  periodic 
drinking  occurs  in  a  way  to  obscure  the  clinical  picture.  In  these 
cases  the  mental  disease  is  accountable  for  the  inebriety ;  but  the 
effects  of  alcohol  so  far  change  the  ordinary  clinical  behavior  that 
it  is  usually  only  after  two  or  three  attacks  that  the  true  nature 
of  inebriety  is  discovered.     The  two  following  cases  illustrate  this : 

One  is  that  of  a  young  man  who  has  been  committed  to  Bloom- 
ingdale  thirteen  times  in  the  past  ten  years.  I  appeared  in  one 
commitment,  but  for  details  of  the  history  I  am  indebted  to  Dr. 
S.  B.  Lyon.  The  original  diagnosis  was  dipsomania,  and  the 
patient's  wife  still  believes  alcohol  to  be  at  the  root  of  all  the 
trouble.  In  the  beginning  of  the  attacks  while  drinking,  he  is 
confused,  delusional,  and  disordered,  with  more  or  less  excite- 
ment.    During  the  attacks,  he  is  abusive,  denounces  his  commit- 


68  CLINICAL   VARIETIES   OF   PERIODIC   DRINKING 

ment  as  unjust,  and  threatens  court  proceedings.  Before  some 
of  the  commitments,  he  has  been  violent  and  made  assaults.  On 
one  occasion  he  improved  sufficiently  to  be  removed  by  his  mother. 
Two  days  later,  he  was  drunk  again  with  return  of  mental  symp- 
toms— he  was  dirty,  disheveled,  excited,  garrulous,  talked  rapidly, 
profanely,  and  disconnectedly — a  condition  lasting  several  months. 
Another  case  of  this  character  is  the  following: 
A  man,  37  years  of  age  when  he  first  came  under  observation, 
had  proved  himself  of  more  than  ordinary  business  capacity.  He 
had  built  up  a  successful  business  and  had  made  shrewd  invest- 
ments. At  college  he  had  been  regarded  as  intemperate.  He 
used  to  go  off  on  sprees,  though  not  a  regular  drinker,  and  acted 
queerly.  He  was  married  in  1904,  the  bride  being  aware  of  his 
reputation.  Shortly  after  his  marriage,  he  refused  for  a  time  to 
speak  to  his  wife,  felt  that  he  had  lost  all  his  money,  felt  that  there 
was  no  hope  for  him,  and  threatened  suicide.  During  this  time 
he  did  not  drink  at  all.  In  August,  1905,  he  began  to  drink  and 
was  intoxicated  most  of  the  time.  At  the  same  time,  he  became 
expansive.  He  bought  a  great  many  things  that  he  had  no  use 
for,  though  he  almost  always  got  good  bargains.  A  piece  of  real 
estate  that  he  bought  at  this  time  was  sold  at  double  the  price  he 
paid  for  it.  He  would  play  the  piano  all  night  and  would  go  out 
in  his  night  clothes  at  four  o'clock  in  the  morning  to  feed  the 
dogs  and  chickens.  He  kept  the  whole  house  awake  with  his 
orgies,  drinking  constantly ;  he  would  lock  himself  in  the  wine 
closet  for  hours  at  a  time.  Though  very  drunk,  he  appreciated 
fully  the  object  of  a  visit  from  two  examiners  in  lunacy  and 
swore  he  would  not  be  locked  up.  Placed  in  confinement,  the  evi- 
dences of  alcoholism  rapidly  left  him  and  he  remained  in  a  con- 
dition of  mild  reasoning  mania.  He  reasoned  with  such  skill 
that  no  sheriff's  jury  would  have  held  him,  and  as  he  insisted  on 
liberty  or  an  inqnirendo^  he  was  discharged.  He  immediately 
became  much  depressed,  bore  no  ill  will  toward  those  active  in 
his  commitment  and  did  not  drink  at  all.  Later  he  resumed  drink- 
ing wine  at  dinner  without  apparent  ill  effect  and  without  intem- 
perance. For  three  years  he  was  well,  temperate,  successfully 
engaged  in  business.  There  was  one  period  of  excitement  and 
intemperance  which  lasted  several  weeks,  but  for  which  no  special 
medical  attention  was  necessary.      In  the  autumn  of   1908  he 


CLINICAL   VARIETIES   OF    PERIODIC   DRINKING  69 

began  to  drink  again.  He  would  insist  on  making  several  cock- 
tails for  everyone  who  called ;  he  wrapped  a  napkin  about  his 
waist,  served  all  drinks  himself  and  said  he  was  the  butler.  And, 
as  before,  would  lock  himself  in  the  wine  closet  for  hours.  He 
developed  persecutory  ideas.  Thought  that  detectives  were  after 
him,  that  the  people  on  the  street  were  making  remarks  about 
him,  that  people  in  neighboring  houses  were  mocking  him.  He 
was  placed,  without  commitment,  in  a  private  sanatorium.  He 
thought  he  was  committed  and  would  not  cross  the  threshold  of 
his  room  in  the  fear  that  the  police  would  get  him.  He  had  devel- 
oped some  important  signs  of  alcoholism.  The  knee  jerks  were 
absent.  And  another  sign,  the  occurrence  of  which  as  an  alco- 
holic symptom  is  overlooked  in  most  text-books,  was  that  the 
pupils  did  not  respond  to  light.  After  a  few  weeks'  abstinence, 
both  the  knee  jerks  and  the  light  reflex  became  normal.  But  he 
still  was  insane  and  was  committed. 

He  was  filthy  in  his  habits  and  would  spend  his  days  making 
messes  of  food  and  odd  bits  of  rubbish,  which  he  called  inven- 
tions. He  was  confined  altogether  for  about  two  months,  at  the 
end  of  which  time  he  was  well  enough  to  be  discharged.  He  again 
became  depressed,  all  delusions  left  him,  and  he  had  no  desire 
to  drink. 

Both  of  the  above  cases  seem  to  have  classed  themselves  pretty 
definitely  as  manic  phases  of  manic-depressive  insanity.  By  some 
peculiarity  of  personal  disposition  or  environment  the  expansive 
periods  announced  themselves  by  sudden  outbursts  of  inebriety; 
and  the  resulting  alcoholism  marred  the  clearness  of  the  mental 
picture.  But  the  diagnosis  was  long  in  doubt,  and  by  the  lay 
mind  both  patients  still  are  believed  to  be  periodic  drinkers. 

Outside  the  sphere  of  well  defined  psychoses  are  many  mental 
states  touching  the  abnormal  and  characterized  by  instability,  by 
impulsiveness,  by  excessive  psychomotor  reactions.  It  seems  rea- 
sonable to  think  that  further  examination  in  this  field  may  throw 
much  light  on  periodic  drinking. 

Many  of  the  psychic  causes  and  the  psychic  effects  of  alcohol 
are  interchangeable.  In  studying  the  mental  states  which  lead  to 
drinking,  we  may  find  one  that  seems  important,  and  mark  it  down 
as  an  essential  cause.  Then,  later,  when  observing  the  effects  on 
character  of  alcoholism,  we  come  again,  with  startling  frequency, 


70  CLINICAL  VARIETIES   OF   PERIODIC   DRINKING 

upon  the  same  feature  which  caught  our  eye  when  studying  causes. 
It  may  have  become,  perhaps,  discolored,  and  present  lines  more 
sinister,  but  is  none  the  less  unmistakably  the  same  as  we  knew 
it  as  a  cause.  Take,  for  example,  fear.  Fear  as  a  cause  of  drink- 
ing has  become  a  proverb,  and  so  requires  neither  exploitation  nor 
comment.  As  a  symptom,  fear  is  disseminated  through  the  whole 
clinical  fabric,  from  the  timidity  of  the  besotted  vagabond  to  the 
wild  terror  of  the  victim  of  alcoholic  hallucinations.  Thus  fear 
is  both  a  cause  and  an  effect.  So  it  is  with  many  other  of  the 
factors  busy  in  the  genesis  of  this  world  disease.  We  see  them 
as  causes  and,  shortly  afterwards,  they  are  looking  at  us  branded 
as  effects.     Like  sheep  at  pasture,  they  jump  their  boundaries. 

Sexual  desires,  wrong  moral  attitudes,  idleness,  jealousy,  all 
appear  indifferently  in  the  category  of  causes  or  effects.  And 
in  studying  the  springs  of  inebriety,  we  may  do  worse  than 
begin  with  the  effects.  Two  of  these  latter — sexual  excitement 
and  jealousy — deserve  especial  scrutiny.  The  relationship  which 
exists  between  the  sexual  appetite  and  the  stimulant  which  best 
arouses  it  needs  only  to  be  mentioned  to  be  recognized.  Indis- 
criminate license,  sexual  perversion,  sexual  crimes,  all  are  the 
results  of  intoxication,  as  readily  appears  in  every  treatise  on 
psychiatry  and  legal  medicine.  But  that  certain  forms  of  alco- 
holism owe  their  existence  to  sexual  desire  is  not  so  well  estab- 
lished. Normal  intercourse  has  nothing  to  do  with  drinking; 
and  the  alcoholic  hilarity  which  enhances  the  popularity  of  the 
brothel  stimulates  desire  rather  than  results  from  it.  But  in 
periodic  drinking,  the  generative  feature  stands  out  more  closely. 
Procreative  tendencies  are  themselves  more  or  less  periodic  in 
their  appearances ;  and  their  impulsive  character  is  revealed  by 
such  degenerates  as  exhibitionists  and  curl  cutters  or  by  such  im- 
perative ideas  as  are  found  in  the  psychoses  which  result  from 
sexual  traumata  in  childhood.  I  have  yet  to  meet  a  periodic 
drinker  who  was  not  an  erotomaniac  as  well.  One  patient 
whom  I  have  observed  for  fifteen  years  and  who  has  been  in- 
carcerated in  almost  every  institution  within  lOO  miles  of  New 
York  has  never  gone  on  a  spree  from  which  harlots  were  ex- 
cluded. With  him,  contemporaneously  with  the  idea  of  the  initial 
drink,  came  the  idea  of  sexual  gratification.  And  when  his 
family  went  to  look  him  up,  they  would  always  find  him  in  a 


CLINICAL  VARIETIES   OF   PERIODIC   DRINKING  ^l 

house  of  prostitution,  never  in  a  bar-room.  It  is  true  that  in 
many  dipsomaniacs,  the  erotic  ideas  do  not  make  their  appear- 
ance until  the  stimulant  has  aroused  desire.  But  in  the  case  just 
described  they  appeared  as  soon  as,  if  not  sooner  than,  the  im- 
pulse to  drink;  and  there  would  be  no  difficulty  in  mustering 
other  cases  of  this  class.  So  it  seems  worth  while  to  give  at- 
tention to  the  hypothesis  that  some  cases  of  dipsomania  arise 
in  the  sexual  centers  rather  than  in  the  motor  cortex — and  that 
they  are  a  part  of  a  general  neuropathic  state  and  are  psycho- 
genic in  origin,  having  no  direct  relationship  to  epilepsy.  Cases 
in  this  class  distinguish  themselves  from  epileptic  dipsomania 
in  that  aggressive  physical  violence  is  not  conspicuous  during  the 
attacks ;  that  the  attacks  can  persist  over  many  years  without  pro- 
nounced mental  deterioration ;  and  that,  as  time  goes  on,  the 
attacks  may  become  less  severe  and  less  frequent. 

Another  variety  of  periodic  drinking  is  sometimes  met  with 
in  personalities  mildly  paranoid,  usually  of  the  jealous  type. 
Jealousy  is  among  the  most  frequent  of  the  psychic  symptoms  of 
chronic  alcoholism,  and  consequently  when  one  encounters  a  case 
of  alcoholism  with  jealous  delusions  one  is  apt  to  infer  that  the 
delusions  are  toxic  products.  But  this  is  not  always  correct.  In 
a  number  of  cases  that  have  come  under  my  notice  subsequent 
events  have  shown  that  the  periodic  drinking  was  a  fortuitous 
circumstance.  The  paranoid  state  was  amplified  by  it,  but  ex- 
isted independently  of  it — and  in  one  case  in  particular  was 
only  moderately  intensified  by  the  alcohol. 

This  case  was  that  of  a  lady  of  highly  neurotic  temperament 
and  a  jealous  disposition.  After  having  borne  her  husband  sev- 
eral children  she  became  infected  with  syphilis.  The  infection 
is  believed  to  have  occurred  at  a  gynecological  operation.  The 
husband  never  had  syphilis.  But  the  occurrence  of  the  misfor- 
tune intensified  the  wife's  jealous  state  of  mind.  She  wished  to 
know  everywhere  her  husband  went ;  would  upbraid  him  for  his 
alleged  attentions  to  other  women ;  and  frequently  insulted  dif- 
ferent female  members  of  her  own  family  on  the  ground  that  her 
husband  was  unduly  attentive  to  them.  Her  attitude  toward 
her  husband  was  fluctuating ;  at  one  time  solicitous  and  affection- 
ate, at  another  she  would  work  herself  up  into  a  jealous  rage, 
upbraiding  him   and   accusing  him   of   all   manner  of   improper 


72  CLINICAL   VARIETIES   OF   PERIODIC   DRINKING 

acts  of  which  he  was  guiltless.  On  these  occasions,  she  would 
take  to  drink,  which  intensified  her  fury.  Once  she  developed 
a  typical  jealous  mania.  She  went  to  the  police  and  set  detec- 
tives on  her  husband's  trail ;  interviewed  the  newspapers ;  threat- 
ened divorce ;  put  a  truly  insane  interpretation  on  the  most  trivial 
circumstances ;  said  she  would  ruin  her  whole  family  if  neces- 
sary, but  that  her  husband  should  be  exposed.  She  was  drink- 
ing heavily  at  this  time  and  those  who  saw  her — police,  detec- 
tives, and  members  of  her  own  and  her  husband's  family — all 
thought  her  action  the  sole  result  of  drink. 

Placed  under  treatment  and  being  brought  to  realize  that  none 
of  her  contentions  would  be  believed  by  anyone  if  she  drank,  she 
stopped  drinking,  and  though  she  stopped  abruptly,  showed  none 
of  the  physical  signs  of  alcoholism.  But  the  mental  symptoms 
kept  on  in  full  activity,  and  for  months  afterward,  although  she 
was  totally  abstemious,  the  psychosis  continued  in   full  flower. 

Another  promising  field  for  future  investigation  as  to  the 
genesis  of  periodic  drinking  should  be  among  the  class  of  emo- 
tional personalities  broadly  embraced  by  the  terms  hysteria  and 
psychasthenia. 

Throughout  the  clinical  range  of  alcoholism,  both  of  the  single 
intoxication  and  of  the  chronic  poisoning,  there  is  disturbance 
in  the  emotional  sphere.  Individual  feelings  such  as  anger,  grief, 
joy,  fear,  attain  undue  prominence,  and  react  to  stimuli  too  easily. 
This  fact  explains  why  cures,  whether  they  be  rehgious,  "  scien- 
tific," or  commercial,  which  appeal  to  the  emotions,  are  the  ones 
which  have  the  greatest  success  with  the  drunkard. 

And  as  we  find  these  psychic  features  as  results,  it  would  not 
be  surprising  if  they  also  figured  as  causes.  We  know  now 
that  many  obsessions,  tics,  morbid  fears,  and  even  certain  para- 
noid states,  had  their  starting  points  in  some  painful  emotional 
experience.  I  believe  that  periodic  drinking,  allied  in  many  ways 
to  these  psychasthenic  or  hysterical  complexes,  will  soon  be 
shown,  in  many  instances,  to  have  had  a  similar  starting  point. 

I  regret  that  no  case  in  my  records  has  been  analyzed  from 
this  point  of  view,  although  in  one  case,  seen  many  years  ago, 
there  seemed  an  intimate  connection  between  the  paroxysms  of 
drinking  and  certain  feelings  of  inadequacy,  which  latter  resulted 
from  unfortunate  surroundings  in  childhood.     The  newer  metli- 


CLINICAL  VARIETIES   OF    PERIODIC   DRINKING  73 

ods  of  psychoanalysis  would  perhaps  have  shown  a  still  closer 
relationship. 

In  closing,  I  would  urge  a  careful  psychological  analysis  of  all 
cases  of  periodic  drinking.  It  is  only  by  such  means  that  the 
proper  curative  measures  can  be  unearthed.  Chronic  alcoholism 
has  some  right  and  title  to  be  considered  a  disease.  But  dip- 
somania, in  most  cases  at  least,  is  not  so  much  a  disease  as  it  is 
disorder  of  personality.  And  the  treatment  must  be  shaped  to 
that  end.  Before  this  is  possible,  the  defects  in  the  personality 
must  be  laid  bare.  The  treatment,  therefore,  is  individualistic, 
varying  in  every  patient  in  accordance  with  the  result  of  the 
analysis  of  him  as  an  individual. 


A  STUDY  OF  SOME  CASES  OF  DELIRIUM 
PRODUCED   BY   DRUGS^ 

By  Dr.  August  Hoch, 

PSYCHIATRIC  INSTITUTE,   N.   Y.    STATE   HOSPITALS 

Cases  of  the  nature  of  those  here  recorded  are  probably  not 
very  rare.  Nevertheless,  during  my  ten  years'  service  at  the 
M'Lean  Hospital,  Waverley,  Mass.,  I  have  had  occasion  to 
observe  only  eight,  four  of  which  are  here  presented.  But  it 
seemed  to  me  of  some  value  to  establish  clearly  the  delirious 
nature  of  these  conditions,  to  analyse  them  carefully,  and  to 
compare  them  with  the  deliria  about  which  we  are  best  informed, 
those  produced  by  alcohol.  The  excellent  monograph  by  Bon- 
hoeffer,^  a  model  of  clinical  analysis,  has  greatly  advanced  our 
knowledge  of  delirium  tremens  and  of  deliria  in  general.  The 
desire  was  very  natural,  therefore,  to  study  deliria  with  a  dif- 
ferent etiology  in  a  similar  manner.  That  the  writer  feels  a 
great  obligation  to  Bonhoeffer,  whose  work  in  part  guided  his 
studies  and  his  conclusions,  he  desires  to  express  at  the  outset. 

The  drugs  to  which  these  deliria  were  attributed  are  chiefly 
bromides,  hyoscine,  various  true  hypnotics,  and  morphine,  and 
it  is  a  notable  fact  that  it  seems  to  be  of  very  little  conse- 
quence which  drug  is  used ;  indeed,  I  have  seen  one  case  in  which 
acetanilid  seemed  to  have  been  the  only,  or  at  any  rate,  the 
most  important  drug.  After  all,  as  is  assumed  in  the  case  of 
alcohol,  the  action  of  the  poison  introduced  is  probably  only  the 
indirect  cause ;  nor  does  it  seem  to  be  the  only  one,  for  in- 
sufficient food,  protracted  loss  of  sleep,  digestive  disorders,  and 
general  exhaustion,  seem  to  act  as  contributory  causes.  We 
may  infer  this  from  the  fact  that  such  factors  are  often  present, 
and  that  we  find  occasionally  conditions  resembling  delirious 
reactions  in  manic  states,  for  example,  after  just  such  causes  have 


*  Read  at  the  New  York  Psychiatrical  Society,  October  4,  1905. 
^  Bonhoeffer,    Die    Geistesstorungen    der    Gewohnheitstrinker,    Gustav 
Fischer,  Jena,  1901. 

75 


76  DELIRIUM    PRODUCED    BY   DRUGS 

been  at  work.  Unfortunately  it  has  usually  been  impossible  to 
determine  the  exact  amounts  of  the  drugs  taken,  and  in  one  case 
the  doses  admitted  seemed  too  small  to  account  for  the  pro- 
found reactions.  Nevertheless,  the  experience  with  all  such 
cases  cannot  leave  any  doubt  regarding  the  importance  of  drugs 
as  an  etiological  factor  in  them. 

Case  i. — Mrs.  H.,  aged  51.  In  the  hospital  from  March  5  to  March  28, 
1903.  The  patient  had  one  sister  who  had  the  opium  habit.  Any  other 
neuropathic  traits  in  the  family  were  denied. 

The  patient  had  never  been  insane,  but  since  the  age  of  30  had  com- 
plained of  very  severe  headaches  which  occurred  at  menstruation,  and  for 
years  had  been  in  the  habit  of  taking  morphine  for  them  to  the  extent  of 
%  to  y2  grain  a  day.  She  is  said  to  have  been  perfectly  well  in  the 
intervals.  For  three  months  before  admission  the  patient  had  not  men- 
struated, after  the  flow  had  been  scanty  for  about  a  year.  Two  months 
before  admission  the  headaches  again  came  on,  and  now  became  con- 
tinuous ;  she  took  morphine,  rising  rapidly  to  a  grain  a  day,  but,  it  is 
said,  no  farther.  This  was  continued  until  admission,  while  in  the 
meantime  bromides  were  added.  These,  it  was  claimed,  were  not  in 
large  doses.  The  patient  had  become  irritable,  and  two  weeks  before 
admission  she  began  to  get  restless,  somewhat  apprehensive,  and  for 
five  or  six  days  before  admission  she  is  said  to  have  been  confused  and  at 
times  dull.  For  a  week  she  had  not  slept  and  had  scarcely  taken  any 
food. 

On  admission  the  patient  appeared  restless,  evidently  heard  voices,  but 
she  showed  no  fear.  She  was  disoriented  and  used  wrong  words.  At  the 
morning  visit  on  the  following  day  she  was  found  with  a  rather  pasty 
complexion,  a  heavily  coated  tongue,  a  temp,  of  99.2°.  Her  breath  was 
foul.  There  was  no  eruption  on  the  body.  There  was  no  evidence  of  any 
palsies;  the  movements  of  the  arms  were  not  ataxic,  but  the  gait  was 
rather  staggering.  There  was  a  general  coarse  tremor  in  the  hands. 
The  reflexes  were  of  normal  intensity.  She  lay  in  bed  tossing  about 
rather  restlessly.  Her  mood  was  one  of  a  whining  depression,  with  some 
irritability,  but  no  apprehensiveness.  She  looked  somewhat  dull,  and  her 
attention  could  at  times  be  attracted  only  with  marked  difficulty,  again 
quite  readily;  but  we  were  struck  with  the  fact  that  now  and  then,  even 
at  the  time  when  we  had  difficulty  in  obtaining  answers,  she  made  occa- 
sional comments  on  things  which  were  said  in  her  hearing.  Hallucina- 
tions were  at  times  quite  prominent;  she  had  spoken  of  hearing  bells 
ringing,  had  seen  pictures  on  the  door,  her  sister  in  the  pillow,  a  man  in 
her  bed,  and  she  tried  to  pick  imaginary  flies  from  the  bed-clothes.  She 
was  completely  disoriented ;  though  she  repeatedly  called  the  physician 
"  doctor,"  the  nurse  "  nurse,"  yet  again  she  miscalled  them.  Paraphasic 
turns  of  speech  were  quite  marked,  as  we  shall  presently  show.  For  the 
two  succeeding  weeks  her  condition  remained  essentially  unchanged,  and 


DELIRIUM    PRODUCED   BY  DRUGS  7/ 

may  be  summarized  as  follows:  Sometimes  she  appeared  dull,  even  to 
the  extent  of  soiling  herself.  Her  attention  varied:  it  either  could  be 
easily  attracted  or  this  was  very  difficult,  and  she  could  be  pricked  with 
a  pin  without  any  reaction.  Her  disorientation  remained,  though  shaded 
off  gradually.  She  thought  she  was  in  New  York  and  other  places ; 
again,  called  people  by  wrong  names.  Her  time  orientation  was  very 
poor.  Sometimes  she  related  delirious  experiences;  for  example,  said 
that  she  had  been  up  the  river  lately  in  a  boat,  or  that  she  had  just  been 
in  the  woods,  where  "  some  money  was  tied  to  a  tree,"  and  the  like. 
The  hallucinations  continued,  and  even  became  more  marked.  She  heard 
voices,  reached  out  her  hands  to  fancied  visitors,  talked  to  the  wall, 
spoke  of  the  girls  upstairs  "  who  have  talked "  about  her,  and  quite 
marked  was  the  fact  that  she  picked  up  imaginary  threads  from  the 
bed-clothes.  Artificial  hallucinations  could  be  produced  by  rubbing  her 
eyes.  On  such  occasions  she  said  she  saw  "  a  fire-place,"  "  woodwork," 
"  shelves,"  "  a  woman  in  a  blue  dress,"  "  all  sorts  of  things."  Reading 
tests  showed  fair  results  at  times ;  again,  she  made  glaring  mistakes,  such 
as  reading  "pollies"  instead  of  "1903."  When  questioned  about  events 
in  her  life  she  varied  a  good  deal,  sometimes  gave  perfectly  absurd 
answers,  e.  g.,  that  she  was  born  in  1881 ;  again,  the  answers  were  ap- 
parently perfectly  correct.  A  few  tests  to  study  her  ability  to  retain  im- 
pressions (Merkfahigkeit)  yielded  results  which  would  make  one  think 
that  this  was  very  poor;  but  the  question  of  attention  was  not  sufficiently 
considered  at  the  time,  so  that  we  must  not  lay  too  much  stress  on  the 
results,  all  the  more  so  since  it  was  found  repeatedly  that  at  the  end  of 
an  examination  she  remembered  incidents  which  had  taken  place  at  the 
beginning  of  it.  Her  talk  may  be  illustrated  by  the  following  examples. 
She  said  spontaneously:  "I'll  never  see  my  mother  any  more;  she  has 
been  trying  to  hold  up  since  she  was  lost."  And  then,  pointing  to  the 
nurse,  she  said,  "  This  is  my  mother.  Please  let  me  go.  There  is  noth- 
ing for  me  to  stay  here.  That's  what  I  was,  freezing.  It  seems  just  like 
she  came  in  the  window."  (What  do  you  mean?)  "Well,  don't  you 
know  there  is  a  store  in  front  of  the  bridge  that  comes  right  down  to  a 
point  of  lace.  She  lived  there,  or  she  did  when  I  lived  there,"  etc. 
"  Down  to  a  point  of  lace  "  is  evidently  a  paraphasic  turn,  a  trait  which 
may  be  further  illuustrated  by  the  following  samples.  "  We  were  com- 
ing down  the  ref  road  ...  I  can't  tell  you  where  it  is,  it's  the  mostly 
jardmar,  in  the  mell,  mell  jar,  in  the  worsted  mill  yard."  Or  in  speaking 
of  Chattanooga,  she  said,  "  Chattanulgo,  Challamutta  ";  and  on  one  occa- 
sion when  she  heard  a  telephone  ringing,  she  said  it  was  the  Chattanooga 
ringing,  or  "  You  are  the  gentleman  I  not  in  the  grocery  store." 

In  general  it  may  be  said,  as  is  the  case  in  these  patients,  that  though 
the  talk  showed  some  shifting  of  subjects,  loosely  connected,  it  was  not 
that  which  made  it  difficult  to  follow  it ;  nor  was  this  a  very  marked  trait, 
as  she  kept  often  to  the  subject  she  had  chosen  fairly  well;  but  it  was  the 
fact  that  she  told  of  delirious  experiences  which  we  knew  nothing  about, 
and  the  talk  was   further  obscured  by  the  paraphasia. 


78  DELIRIUM    PRODUCED    BY   DRUGS 

After  the  two  weeks  the  patient  gradually  became  perfectly  clear, 
orientation  was  excellent,  the  hallucinations  disappeared,  and  she  talked 
very  naturally.  It  was  all  the  more  striking  that  with  this  clearness  she 
retained  for  a  number  of  days  a  belief  in  some  of  her  delirious  experi- 
ences, without  however  showing  an  adequate  affective  reaction.  Thus  she 
claimed  that  the  nurse  had  told  her  that  she  had  killed  a  man,  and  said 
she  knew  it  was  her  husband.  She  explained  that  at  home  her  husband 
discharged  a  nurse,  and  that  the  latter  followed  him  to  the  barber  shop 
and  shot  him  through  the  thumb.  When  questioned  retrospectively  about 
the  events  which  had  occurred  in  the  hospital,  it  was  found  that  the 
very  first  part  was  practically  a  blank  to  her,  but  that  after  that  she  re- 
membered quite  a  number  of  things,  which,  however,  were  not  put 
together  in  anything  like  a  sequence.  She  was  taken  home  before  she 
had  entirely  ceased  to  believe  in  some  of  her  delirious  experiences, 
although  she  did  not  at  all  react  to  them. 

Case  2. — Mrs.  W.,  aged  30.  In  the  hospital  from  May  23  to  August 
3,  1903.  Her  maternal  grandmother  was  insane  for  fifteen  years  until 
her  death  at  the  age  of  60 ;  her  mother  had  repeated  attacks  of  "  nervous 
prostration,"  and  one  of  the  mother's  brothers  was  an  epileptic.  A 
paternal  uncle  had  an  attack  of  insanity. 

The  patient  herself  had  "  nervous  prostration  "  when  22,  a  condition 
in  which  she  complained  of  considerable  physical  weakness,  also  of  much 
pain  in  head  and  spine,  and  is  said  to  have  been  very  "  hypochondriacal." 
She  was  in  bed  for  months.  She  was  married  two  years  after  the  onset, 
but  only  two  years  later,  i.  e.,  four  from  the  beginning,  was  she  con- 
sidered really  well. 

Three  months  before  admission  the  patient  is  said  to  have  had  an 
attack  of  "  grippe."  She  was  weak  after  it,  complained  of  palpitation, 
and  was  considerably  worried  about  it.  She  had  to  remain  in  bed,  be- 
came nervous  and  irritable,  and  more  and  more  worried  about  her 
condition.  It  is  claimed  that  she  would  sometimes  stare  for  half  an  hour 
at  a  time.  A  month  before  admission  she  attempted  suicide  for  the 
first  time,  and  was  henceforth  very  insistent  in  her  attempts.  Three  weeks 
before  admission  there  were  occasional  spells  of  mental  clouding,  and  for 
a  week  before  admission  she  had  been  rambling,  noisy,  resistive;  finally 
confused,  untidy,  hallucinating,  eating  almost  nothing  for  some  days. 

Fortunately  we  have  a  good  account  of  the  drugs  which  this  patient 
received.  It  must  be  remembered  that  she  was  admitted  on  the  twenty- 
third  of  May.  From  April  i  to  11  she  was  given  10  grains  of  bromide 
at  night.  From  the  eleventh  until  the  twenty-seventh  it  was  replaced 
by  18  grains  of  trional,  repeated  if  necessary.  From  April  26  to  May  3 
she  had  60  drops  of  Tr.  hyoscyamus  a  day.  From  May  3  until  admission 
she  had  regularly,  at  first  60,  then  120  grains  of  bromide,  plus  15  drops  of 
Tr.  gelsemium  a  day.  In  addition  to  that  she  had,  for  the  week  preceding 
admission,  altogether  2^  grains  of  morphine  and  j^^  of  hyoscine.  And 
finally  she  was  given  Tr.  passiflora,  5  to  10  drops,  every  2  to  3  hours ;  later, 
30  drops  at  longer  intervals. 


DELIRIUM    PRODUCED   BY   DRUGS  79 

The  patient  was  admitted  with  a  temperature  of  ioo°  F.,  sallow  appear- 
ance, foul  breath,  heavily  coated  tongue,  pulse  lOO.  She  was  restless, 
shouted  for  her  husband,  spoke  of  hearing  her  people  murdered,  of  seeing 
coffins,  men  with  revolvers.  She  frequently  seemed  to  pick  up  things 
from  the  bedclothes,  and  when  questioned  said  she  saw  bugs  and  threads. 
Her  voice  was  thick  and  her  stream  of  talk  fragmentary.  She  was  com- 
pletely disorientated.  At  the  morning  visit  her  physical  state  was  the  same 
as  described.  In  addition  it  was  found  that  there  was  no  tremor,  but 
marked  exaggeration  of  reflexes,  with  pronounced  ankle  clonus,  in- 
exhaustible on  the  right  side,  exhausted  after  lo  to  12  motions  on  the 
left.  Babinski  absent.  She  lay  in  bed  quietly,  mumbling  something  to 
herself,  occasionally  calling  out,  evidently  in  response  to  hallucinations, 
sometimes  picking  imaginary  things  from  the  bedclothes.  She  appeared 
dull.  The  mood  was  indifferent,  there  was  neither  fear  nor  any  evident 
depression  or  exhilaration.  It  was  sometimes  very  difficult  to  attract  her 
attention,  again  more  easy.  Sometimes  she  commented  on  slight,  quite 
unobtusive  noises,  such  as  a  distant  train.  Orientation  was  poor.  She 
said  she  did  not  know  where  she  was,  did  not  know  the  people,  but  she 
gave  the  month  as  May,  the  year  as  1903,  then  1902.  Again,  she  said  she 
was  at  her  sister's  house,  but  frequently  called  the  doctor  "  doctor,"  the 
nurse  "  nurse." 

Her  talk  may  be  illustrated  by  the  following.  When  asked  how  long 
she  had  been  sick,  she  said,  "  I  have  been  sick  eight  or  ten  weeks — that 
is  if  I  speak  right — now  my  folks  tried  to  lose  me,  they  were  hunting 
for  me."  (Did  you  see  them?)  "I  could  not  hear  a  sound,  only  her 
[nurse],  and  she  will  kill  me"  (no  affect).  "They  all  say  I  was  afraid 
because  I  went  to  a  store  on  Tremont  Ave.  They  would  not  let  me 
have — well,  she  would  not  let  me — have  anything  to  do — you  remember 
that  [to  nurse] — she  can't  find  out.  I'm  growing  hazier  and  hazier — but 
this  forenoon,  well,  I'll  tell  you  what  she  did.  I  see  her  object  in  it 
now.  I  hadn't  thought  of  it.  I  have  been  moved  so  often.  We  have 
moved  around  in  the  daytime — in  the  night — we  have  moved  all  around, 
I   don't  know  how  many  things,"  etc. 

What  is  not  brought  out  in  this  sample  is  her  paraphasic  turns,  which, 
nevertheless,  were  quite  marked.  Thus  she  said,  in  good  connection, 
"That  is  all  the  satisfaction  I  can  get,  and  I  am  satisfaction."  Or  when 
asked  the  day,  she  said,  "  I  don't  know,  I  haven't  seen  a  map  for  ages. 
I  am  just  8:30  May  something."  Or  again,  "  Are  you  the  gentleman  that's 
marrying  this  house?"  Or,  "He  make  it  distinct  enough  that  I  would 
not  get  well.  Distinct,  extinct  enough,  he  made  it  excitement  enough," 
etc. 

When  asked  memory  questions  she  varied,  evidently  owing  to  her 
variation  in  responsiveness.  She  gave  her  age  correctly.  (Have  you  a 
child?)  "Yes,  three  years  ago"  (correct).  (Is  the  child  living?)  "No, 
dead"  (incorrect).  (How  long  ago  since  it  died?)  "Two  years." 
(What  did  it  die  of?)  "Still-birth."  (What?)  "Two  years  ago  the 
8th  of  February."     (What  happened  then?)     "A  boy  was  born  to  me." 


80  DELIRIUM    PRODUCED    BY   DRUGS 

(How  long  did  he  live?)  "Oh.  I  was  taken  sick  on  the  eighth  and 
he  was  born  on  the  ninth."  (Is  the  boy  living  now?)  "Yes."  (What  is 
his  name?)  She  gave  it  correctly.  (Have  you  ever  lost  a  child?)  "  No" 
(correct).  (How  old  is  your  boy?)  "33."  (No,  your  boy?)  "3" 
(correct).  Then  she  was  asked,  "What  is  9  times  15?"  She  said  19. 
(7X13?)  "21."  (8X9?)  "72."  (16X12?)  "72."  (What  is  the 
capital  of  the  U.  S.?)  "Boston."  (Capital  of  Maine?)  "45."  (Capital 
of  Maine?)  "Capital  of  Maine?  75"  (What  is  75?)  "A  number." 
Then  she  was  again  asked  impressively,  and  she  said  correctly,  "  Augusta." 

In  addition  to  the  hallucinations  above  described,  artificial  hallcina- 
tions  could  be  produced  by  rubbing  her  eyes.  She  said  she  saw  "  a  horse- 
car  on  the  street,"  "  a  post,"  "  a  white  post,"  "  people  and  a  dog."  (What 
kind  of  people?)  "Mostly  Chinese  women."  (What  color  of  dresses?) 
"  Mostly  white  dresses.  I  saw  a  cap  just  now — all  kinds  of  things,  houses 
and  everything  else."  When  told  to  open  the  eyes  she  said,  "  Now  I  see 
a  bunch  of  grapes."  Asked  what  she  saw  on  the  ceiling,  she  said, 
"  Grapes — single   grapes,    small   and   large   ones." 

Just  as  we  found  in  the  other  cases,  this  woman  made  striking  mistakes 
in  her  reading. 

This  condition  lasted  about  ten  days,  while  the  more  marked  symptoms 
gradually  faded,  the  tongue  became  clean,  the  reflexes  normal,  the 
orientation  became  much  better,  the  paraphasia  was  slight,  the  talk  was 
much  clearer,  but  in  spite  of  all  this  improvement  she  continued  to 
believe  in  the  delirious  experiences  and  for  a  time  hallucinations  per- 
sisted. Although  she  finally  cleared  up  altogether,  she  held  on  to  some 
delirious  experiences  almost  to  the  end,  while  at  the  same  time  she 
showed  a  certain  mental  sluggishness. 

Case  3. — Mrs.  E.,  age,  43.  In  the  hospital  from  July  22  to  September 
15,  1904.  Heredity  is  denied,  and  the  patient  has  never  before  been  insane. 
A  year  before  admission  she  had  a  good  deal  of  worry.  She  lost  flesh 
and  got  weak,  slept  poorly,  and  it  is  stated  that  at  that  time  she  took 
a  considerable  amount  of  morphine,  but  that  she  had  not  taken  any  for 
three  months.  For  about  three  weeks  she  has  felt  very  exhausted,  slept 
poorly,  complained  of  many  pains,  and  it  is  stated  that  a  great  many 
drugs  were  then  given  her,  but  we  were  unable  to  find  out  just  what.  She 
got  steadily  worse,  finally  somewhat  confused,  and  three  weeks  before 
admission  she  was  sent  to  Boston.  There  she  had  to  be  looked  after, 
had  to  be  dressed,  fed,  and  gradually  became  excited  and  at  times  fearful, 
confused,  so  that  twelve  days  before  admission  she  was  taken  to  a  small 
hospital,  where  she  was  dull,  untidy,  restless,  had  hallucinations  of  hear- 
ing and  vision. 

In  this  hospital  she  was  again  given  hypnotics,  but  as  has  often  been 
our  experience,  the  guilty  physicians  are  very  apt  to  be  exceedingly  gen- 
eral in  their  answers  to  letters  of  inquiry  about  drugs. 

The  patient  was  brought  to  us  in  a  state  of  marked  dulness  and 
hebetude ;  she  showed  a  tendency  to  keep  her  eyes  closed,  was  untidy, 
her  mouth  was  dry,  presented  sordes,  the  tongue  was  heavily  coated,  the 


DELIRIUM    PRODUCED   BY   DRUGS  8 1 

breath  foul,  the  pulse  rather  weak  (loo).  The  internal  organs  presented 
no  abnormality.  The  reflexes  were  normal.  There  was  no  terror.  She 
lay  muttering,  speaking  indistinctly  and  thickly,  but  when  her  atten- 
tion was  attracted  her  talk  was  much  more  connected  and  the  voice 
much  less  thick.  Sometimes  it  was  easy  to  attract  her  attention;  again, 
difficult.  But  it  was  quite  striking  that  she  repeatedly  caught  up  state- 
ments made  within  hearing  and  commented  on  them.  Her  train  of 
thought  was  at  times  difficult  to  follow,  partly  on  account  of  paraphasic 
utterances,  partly  because  she  spoke  of  things  irrelevant  to  the  situa- 
tion. But  she  kept  on  the  chosen  subject  remarkably  well.  The  answers 
were  often  quite  irrelevant,  evidently  because  she  either  paid  no  atten- 
tion to  the  question  or  because  of  her  paraphasic  turns.  We  may  give  a 
few  examples.  When  asked  what  is  two  times  two,  she  said  "  two  over  " ; 
and  again,  asked  what's  two  times  two,  '  that  what  I  said,  you  would 
think  I  was  crazy,  a  woman  of  75  to  make  me  marry"  (she  had  spoken 
of  that  before),  "to  be  asked  why  I  did  not  marry  such  a  woman" 
(paraphasia).  Then  turning  to  the  nurse:  "Florence.  No,  that  isn't 
Florence.  I  said  '  put  that  feather,  over  there,'  and  Florence  said,  *  No, 
I  won't  put  that  feather  over,' "  etc. 

The  data  of  her  life  were  at  times  given  well,  again  poorly.  She  was 
totally  disoriented,  miscalled  people.  Even  simple  multiplications  were 
done  poorly.  Her  mood  was  either  indifferent  or  somewhat  euphoric. 
Hallucinations  were  present  and  frequent,  especially  those  of  hearing, 
and  to  a  lesser  degree  those  of  sight.  Quite  striking  were  the  tactile 
hallucinations,  or  tactile  and  visual  combined,  which  were  manifested  by 
her  imaginary  picking  up  objects.  Her  ability  to  retain  impressions  tested 
in  the  ordinary  way  (given  a  number  of  4  digits  to  remember)  appeared 
poor,  but  here  again  we  must  add  that  such  a  test  is  only  of  value  if 
the  mental  responsiveness  is  taken  into  account.  Paraphasia  was  pro- 
nounced. Interesting  were  the  results  when  objects  were  shown  to  her. 
They  were  evidently  in  part  due  to  a  disorder  in  apprehension,  so  clearly 
brought  out  in  Case  4,  and  quite  striking  was  also  the  influence  persevera- 
tion. The  following  samples  may  be  mentioned.  (Knife.)  "Brick 
house."  (Knife.)  "Those  are—"  (thinking).  (Tell  me.)  "Knife." 
(Bunch  of  keys.)  "A  key  ringer — ringer  for  keys."  (Watch.)  "Keys." 
(Charm.)  "A  charm."  (Spectacles.)  "Those  rings  which  go  on." 
(Cuff.)  "Keys,  cuff  of  keys  with  a  key-note  in  it."  (Pink.)  "Pink." 
(Palm  leaf  fan.)  "Fan."  (Brown  book.)  "Bible"  (Hand-glass.) 
"Looking-glass."  (Comb.)  "I  don't  know — that's  my  black  comb." 
(Hair-brush.)  "Comb.  It's  a  hair  brush."  (Closed  fan.)  "A  fan,  a 
parasol,  a  very  little  parasol."  (Opened  fan.)  "  A  fan,  a  parasol." 
(Cuff  button.)  "A  gold  ring."  (50  cents.)  "A  quarter."  (25  cents.) 
"A  quarter.""  (50  cents.)  "A  quarter."  (5  cents.)  "10  cents."  (One 
cent.)     "5  cents." 

Three  days  after  entrance  the  attention  was  attracted  with  greater 
ease,  but  the  paraphasia  persisted  to  a  marked  degree.  She  read  very 
poorly.     For  example,  when  made  to  read  "  bats  have  proportionately  the 

7 


32  DELIRIUM    PRODUCED    BY   DRUGS 

longest  ears  and  the  oddest  shaped  noses  in  the  whole  animal  kingdom," 
she  read  "  Bates  properly  continue  the  largest  earnestly  and  clearly  noses 
of  the  kind,  of  the  innumerable  kind."  When  she  was  shown  pictures  she 
showed  marked  abnormalities,  pointed  out  birds  where  there  were  none, 
called  a  piece  of  bread  in  the  hand  of  a  little  child  ''  a  cucumber  squash," 
saw  "  a  lobster  claw  "  on  a  piece  of  paper  which  contained  only  indistinct 
marks,  not  at  all  suggestive  of  a  lobster  claw  to  a  normal  person,  or 
she  caller  three  lambs  "three  cans"  (paraphasic?).  At  that  time  she  was 
still  disoriented  as  to  place.  In  regard  to  time  she  knew  the  month  and 
year,  but  nothing  more.  She  miscalled  persons,  but  not  consistently.  She 
gave  no  one  a  correct  name,  but  called  the  doctor  "  doctor,"  the  nurse 
"  nurse."  The  hallucinations  continued.  She  heard  voices,  and  still  picked 
imaginary  things  from  her  bed-clothes.  In  regard  to  the  disorientation, 
it  may  be  mentioned  that  she  thought  she  was  at  home,  or  in  the  house  of 
a  friend.     She  repeatedly  told  of  delirious  experiences. 

In  a  few  more  days  the  hallucinations  left,  she  became  perfectly  clear 
and  the  attention  was  good,  but  she  still  called  the  place  wrongly,  still 
uttered  delirious  experiences.  Thus  she  told  of  an  accident  which  had 
happened  in  which  her  mother  had  been  injured,  and  claimed  that  the 
examining  physicain  had  been  called  in  and  had  operated  on  the  mother  at 
her  home.  Gradually  she  cleared  up  entirely,  not  only  from  her  delirium, 
but  from  the  condition  which  had  originally  led  to  the  giving  of  drugs. 

Case  4. — Amelia  G.,  aged  39.  Dressmaker.  Admitted  January  11, 
1905. 

The  patient  has  some  psychopathic  heredity,  and  it  is  said  that  she  was 
always  of  a  suspicious  nature,  was  easily  frightened,  and  inclined  to  be 
quite  hypochondriacal  in  the  sense  of  making  a  great  deal  of  small  ail- 
ments. For  ten  years  she  complained  much  of  pain  in  the  neck  and  head, 
but  on  the  whole  was  able  to  do  her  work. 

Six  weeks  before  admission  she  complained  more  of  the  pain,  became 
depressed,  despondent,  listless ;  sometimes  she  was  restless. 

Five  days  before  admission  she  became  more  depressed,  self-accusatory, 
and  sat  for  hours  without  speaking.  Soon  after  this  she  began  to  "  talk 
queerly,"  said  people  were  dead,  that  she  had  killed  six  little  children. 
She  also  said  that  the  top  of  her  head  was  "  blown  up."  She  claimed  that 
her  mind  was  gone.  At  the  same  time  she  showed  indications  of  morbid 
self-reference,  thought  things  which  were  done  had  a  peculiar  meaning, 
and  she  fancied  that  people  looked  at  her.  A  few  days  before  admission, 
hallucinations  began ;  she  answered  voices,  and  she  saw  "  red  devils  crawl- 
ing over  the  sister's  jacket,"  "a  little  angel  walking  round  the  rim  of  her 
drinking  cup."     She  was  often  seen  staring. 

For  about  a  week  she  had  eaten  very  little  and  had  slept  very  poorly. 

Now,  this  woman  had  been  given  liberal  doses  of  bromides  in  the  six 
weeks  preceding  her  admission  to  the  hospital.  We  were  unfortunately 
unable  to  find  out  the  exact  doses,  but  it  is  said  that  she  was  given  a 
teaspoonful  of  a  bromide  mixture  every  three  hours.  The  fact  that  at 
entrance  she  had  marked  acneform  eruption  on  her  body  also  supports  the 


DELIRIUM    PRODUCED   BY   DRUGS  83 

supposition  that  she  had  been  heavily  dosed.  Besides  these  bromides,  she 
was  given  hypodermic  injections,  the  nature  of  vi^hich  we  could  not  find  out. 

At  entrance  the  patient  showed,  as  was  stated,  an  acneform  eruption; 
the  tongue  had  a  heavy  brown  coat;  her  breath  was  foul.  Her  gait  was 
somewhat  unsteady,  resembling  that  of  cerebellar  ataxia.  But  there  was 
no  tremor,  the  reflexes  were  normal.  The  pupils  could  not  be  tested  on 
account  of  lack  of  co-operation.  She  showed  marked  tenderness  and  pain 
over  the  joints  of  the  legs,  but  no  swelling.  Her  urine  showed  a  slight 
trace  of  albumin,  but  nothing  pathological  otherwise,  except  a  very  high 
specific  gravity,  .1041.  Temperature  normal.  Pulse  and  respiration 
showed  nothing  of  any  consequence. 

She  wandered  aimlessly  about,  presenting  the  uncertain  movements 
above  described.  Her  expression  was  strikingly  empty,  but  not  immobile. 
She  made  the  impression  of  being  absorbed  in  vague  thoughts,  ard  very 
often  she  did  not  answer  questions,  or  what  she  did  say  had  no  bearing 
on  what  she  had  been  asked,  but  was  either  a  vague  allusion  to  the 
"  Blessed  Virgin  "  or  the  like,  or  a  repetition  of  something  she  happened 
to  hear,  and  the  result  was  the  same  whether  complicated  or  the  most 
simple  questions  were  asked.  But  she  showed  her  tongue,  and  reacted 
quickly  to  pin  pricks.  Quite  striking  was  an  aimless  resistance,  blind  in 
character,  yet  without  an  afifectful  background  to  it,  making  rather  the 
impression  of  a  tendency  to  perseveration,  a  trait  which  was  later  on 
brought  out  more  clearly.  Interesting  is  the  fact  that  with  this  there  was 
at  times  a  tendency  to  catalepsy,  and  above  all  a  marked,  though  not 
consistent,  echopraxia,  even  to  tests.  It  should  be  noted  that  in  spite  of 
all  these  traits  she  at  times  occupied  herself  with  the  physician,  fumbling 
aimlessly  about  his  clothes  and  the  like. 

Next  day  the  condition  was  quite  different  and  remained  different  for 
about  a  week,  after  which  time  it  very  gradually  shaded  into  a  typical 
state  of  manic  depressive  retardation,  which  persisted  so  long  as  I  observed 
her.  The  condition  which  developed  on  the  second  day,  and  which  we  shall 
presently  describe,  was  a  delirious  state,  and  for  some  weeks  after  the 
height  of  it  was  passed  the  slight  delirious  traits  persisted,  masking  the 
manic-depressive  retardation,  so  that  for  quite  a  while  the  case  presented 
considerable  difficulties  to  the  correct  interpretation. 

During  the  delirious  condition  she  was  at  first  completely  disoriented 
as  to  place,  persons,  time,  even  the  time  of  the  day.  Whether  this  had 
been  so  on  the  first  day  we  were  unable  to  decide,  because  she  did  not 
answer  questions.  It  could  be  established,  after  the  first  day,  because 
she  responded  more  readily,  although  she  had  a  marked  tendency  from 
time  to  time  to  get  into  a  similar  staring  condition  as  at  first,  and  even 
to  become  decidedly  drowsy.  These  variations  in  her  responsiveness  were 
quite  marked,  so  that  at  times  it  was  impossible  to  attract  her  attention. 
When  thus  absorbed  she  did  not  react  to  pin  pricks,  and,  at  these  times 
also,  it  was  found  that  she  would  firmly  hold  on  to  anything  which  she 
happened  to  have  in  her  hands,  so  that  it  could  not  be  taken  away  from 
her  except  when  it  was  possible  by  putting  some  other  object  in  front  of 


84  DELIRIUM    PRODUCED    BY   DRUGS 

her  eyes  to  forcibly  attract  her  attention  to  that.  Again,  when  looking  at 
anyone,  she  would  follow  that  person  with  her  eyes  when  he  moved  about. 
All  this  made  the  impression  of  a  peculiar  fascination  and  perseveration. 
During  this  time  she  lay  in  bed,  often  appearing  rather  dull.  She  halluci- 
nated, saw  "  staggering  things  with  long  legs,"  "  a  bird  "  in  the  physician's 
hair,  "  lots  of  children  at  the  end  of  the  hall,"  or  she  saw  faces  in  the 
transom,  and  heard  voices.  But  she  had  evidently  no  hallucinations  of 
touch.  Her  talk,  which  was  rather  scanty,  was,  however,  clear,  and  there 
were  only  occasional  paraphasic  turns  in  it,  but  these  were  distinct.  She 
produced,  however,  a  number  of  delirious  experiences.  She  said  she  had 
been  "  in  a  dry  goods  store  this  morning,"  that  she  had  gone  down  a  long 
street,  and  the  like. 

The  mood  during  all  this  time  was  strikingly  indifferent,  even  when 
she  uttered  occasional  depressive  ideas. 

We  then  made  some  experiments  daily  in  order  to  study  more  closely 
the  hallucinations,  the  process  of  apprehension,  and  her  ability  to  retain 
recent  impressions.  In  all  these  experiments  the  question  of  mental  re- 
sponsiveness had  to  be  taken  into  consideration,  so  that  we  also  made 
some  tests  regarding  this.^ 

Let  us  first  consider  the  hallucinations.  Like  all  the  other  cases,  this 
patient  showed  marked  artificial  hallucinations,  i.  e.,  when  the  eyes  were 
pressed  upon  and  she  was  asked  what  she  saw,  she  said,  for  example,  "  a 
whole  pile  of  black  iron  rails  " ;  later,  "  I  see  a  little  girl  of  13  or  14  hold- 
ing a  doll."  (What  kind  of  dress  has  she  on?)  "A  gray  one."  "I  see  a 
baby  carriage."  She  also  said,  "  I  see  a  man,"  or  again,  "  It  looked  like 
a  yellow  suit  with  brown  buttons  on  it."  As  will  be  remembered,  it  was 
Liepmann  who  first  showed  that  such  hallucinations  could  be  produced  in 
alcoholic  deliria. 

When  pictures  were  shown  to  her  the  halluciantions  were  also  very 
marked,  just  as  had  been  the  case  in  Mrs.  H.  Thus  in  one  picture  which 
she  first  described  quite  well,  she  added,  "  and  there  is  a  man  crawling 
under  the  fence."  In  another  picture  she  pointed  out  a  cat  in  the  grass, 
where  there  was  none.  After  having  described  the  essentials  of  a  third 
picture  correctly,  she  added,  pointing  to  rather  small,  indistinct  geese, 
that  they  were  birds.  A  small  brown  chicken  she  called  a  squirrel. 
Finally  she  saw  "  a  big  snake  and  a  big  green  lizard."  (The  picture 
showed  a  patch  of  grass.)  When  she  was  shown  a  fourth  picture  she 
again  described  the  essentials  correctly,  but  when  she  came  to  an  in- 
distinct chick  she  said,  "  There  is  something  here  but  I  can't  see  it."  Later 
she  saw  "  bugs  running  up  the  shrubbery,"  and  finally  "  a  long  green 
snake."  In  other  words,  the  patient  began  invariably  by  describing  the 
picture  correctly.  That  was  at  a  time  when  her  attention  was  attracted  by 
a  new  picture,  but  soon  she  began  to  hallucinate,  and  as  we  shall  presently 

*  These  experiments  I  made  in  conjunction  with  my  friend  and  asso- 
ciate, Dr.  S.  I.  Franz,  to  whom  I  wish  here  to  extend  my  thanks  for  his 
assistance. 


DELIRIUM    PRODUCED    BY   DRUGS  S$ 

point  out,  she  began  to  see  indistinctly,  and  when  one  watched  her  further 
she  was  very  apt  to  go  oflf,  as  it  were,  i.  e.,  to  get  into  a  staring  state 
similar  to  the  one  described  on  the  first  day,  or  she  got  distinctly  drowsy. 
That  she  does  not  see  well  we  infer  from  the  fact  that  she  pointed 
to  the  chick  saying,  "  I  cannot  see  that."  However,  this  was  rather  iso- 
lated and  usually  she  hallucinated.  Some  years  ago  I  had  occasion  to 
observe  a  case  of  Korsakow's  psychosis  quite  early  in  the  course.  This 
man  resembled  in  many  ways  the  patient  under  consideration.  In  that 
case  it  was  very  evident  that  he  had  periods  when  his  vision  was  very 
indistinct.  He  also  hallucinated  at  times  during  these  periods  of  indis- 
tinctness of  vision;  more  often  this  was  not  the  case.  The  Korsakow  case 
differed  very  markedly  from  Miss  G.  by  making  a  much  more  natural 
impression,  but  from  time  to  time  he  had  peculiar  short  spells  in  which  he 
seemed  to  wander,  would  not  respond,  and  sometimes  even  his  attention 
could  not  be  attracted  for  the  space  of  a  minute  or  so.  My  attention  was 
first  called  to  this  condition  while  I  was  making  a  sensory  examination. 
He  would  answer  promptly  for  a  time,  then  suddenly  he  could  be  touched 
or  pricked  without  making  any  response.  In  order  to  study  this  more 
carefully  we  applied  the  following  tests.  We  read  to  him  columns  of 
thirty-two  figures  each,  among  which  five  threes  were  irregularly  dis- 
tributed. He  was  asked  to  tap  the  table  every  time  he  heard  a  three. 
He  would  often  allow  from  one  to  five  threes  to  pass  unnoticed,  on  one 
occasion  fourteen  in  four  lines,  and  altogether  14  per  cent.  When  this 
man  was  shown  series  of  letters  (we  used  quite  large  ones)  or  pictures, 
he  would  at  times  name  or  describe  them  very  well.  At  other  times  he 
would  say,  "  it's  dull,"  or  "  it's  blurred,"  or  "  it's  going,"  or  simply,  "  I 
can't  see  it."  Although  the  most  frequent  result  was  that  his  vision  be- 
came merely  blurred,  he,  at  times,  hallucinated  like  Miss  G.  For  example, 
on  one  occasion,  instead  of  seeing  a  letter  he  said  he  saw  "  a  procession  of 
the  Knights  of  Pythias."  A  few  times  he  also  had  auditory  hallucinations 
in  such  periods.  Questioned  about  these  states  he  said,  "  My  mind 
wanders";  or  again,  "I  get  forgetful  at  those  times."*  We  see,  then, 
that  this  patient  had  short  periods  during  which  his  "  mind  wandered." 
In  these,  his  attention  could  at  times  not  be  attracted;  at  other  times  he 
showed  a  peculiar  visual  disorder,  and  with  it  a  tendency  to  hallucinations. 
The  analogy  with  the  case  of  Miss  G.  is  obvious.  The  most  likely  cause 
of  this  visual  disorder  seems  to  be  a  disorder  of  accommodation  and  fixa- 
tion. There  can  be  no  doubt  but  that  this  indistinctness  of  vision  plays  a 
part  in  the  production  of  the  visual  hallucinations,  or  more  correctly, 
illusions.     The  most  important  part,  however,  we  must  admit  to  be  the 

*  An  interesting  feature  about  the  case  was  quite  marked  variation  in 
the  blood-pressure,  distinctly  perceived  by  the  touch.  But  I  was  never 
sufficiently  satisfied  to  declare  that  they  were  synchronous  with  these 
periods.  On  one  occasion  Dr.  Amadon  established  the  fact  that  the 
fundus,  which  in  the  beginning  of  the  ophthalmoscopic  examination  ap- 
peared normal,  later  was  much  paler. 


86  DELIRIUM    PRODUCED   BY   DRUGS 

mental  alteration,  namely,  the  peculiar  dipping  down  to  lower  levels  of 
consciousness — if  this  term  may  be  permitted — a  condition  of  mental 
dissociation  analogous  to  dreaming  or  to  the  hypnagogic  state,  in  which 
hallucinations  are  also  present.  And  we  all  know  that  in  the  state  pre- 
ceding sleep  our  vision  becomes  indistinct,  as  everyone  has  experienced 
when  trying  to  read  a  book  while  having  difficulty  in  keeping  awake. 

We  will  now  return  to  the  case  of  Miss  G.,  and  to  the  experiments  on 
the  proc.ss  of  apprehension.  We  wished  to  see  whether  a  short  exposure 
of  letters  or  words  or  pictures  was  sufficient  for  her  to  apprehend  correctly. 
We  used  for  that  purpose  a  small  screen  of  a  photographic  apparatus,  the 
exposure  of  which  varied  somewhat  between  one  tenth  and  one  fourth  of  a 
second.  Among  seventy  tests  we  found  that  sometimes  we  obtained,  even 
with  the  shortest  exposures,  remarkably  good  results,  which  in  no  way 
differed  from  the  normal.  This  was  especially  the  case  with  simple  letters 
or  with  words.  At  other  times  the  results  were  remarkably  poor,  and  again 
the  patient  hallucinated.  The  influence  of  the  clearness  of  the  object  was 
evidently  of  some  importance.  Thus,  when  an  indistinct  bird  was  shown, 
she  said,  "  I  see  three  cows  in  a  field  and  a  man  coming  along  with  a  rake 
over  his  shoulder."  Bonhoeffer,  in  studying  his  alcoholic  deliria,  has 
pointed  out  that  by  means  of  the  sesthesiometer  we  sometimes  get  normal, 
again  very  bad  results ;  in  fact,  his  findings  are  perfectly  analogous  to  ours. 
We  may  say  that,  from  time  to  time,  there  is  a  most  profound  inability  to 
apprehend,  but  that  this  is  due  entirely  to  the  specific  delirious  alterations, 
the  dipping  down  to  lower  levels  of  consciousness ;  while  at  other  times 
we  obtain  normal  results. 

Somewhat  more  complicated  is  the  study  of  the  retentive  faculty 
(Merkfahigkeit).  When  we  gave  the  patient  eight  consecutive  figures  to 
repeat,  she  was  able  to  give  on  an  average  about  four;  a  few  times,  how- 
ever, she  gave  seven  and  six,  sometimes  none  or  only  one  (nineteen  tests). 
It  is  possible  that  seven  and  six  represent  her  normal  limit. 

Other  tests  were  the  following.  The  patient  was  given  pairs  of  words 
— (i)  words  connected  by  habitual  association,  such  as  "bread  and 
butter";  (2)  pairs  of  words  connected  by  internal  association,  e.  g.,  "head 
— hair";  (3)  pairs  of  words  which  were  not  connected  at  all,  such  as 
"  screen — ball."  After  times  varying  from  thirty  seconds  to  two  minutes, 
thirty  minutes,  an  hour,  or  even  one  or  two  days,  she  was  given  the  first 
word  and  had  to  supply  the  second.  We  found  that  she  was  unable  to 
retain  words  which  were  not  connected,  but  we  made  few  experiments  with 
thejc.  Among  the  words  with  internal  connection  she  retained  31  per 
cent. ;  among  those  with  habitual  association  57  per  cent.  It  was  generally 
found  that  when  she  was  able  to  retain  the  words  for  thirty  seconds  she 
also  cojld  retain  them  for  much  longer  periods,  and  the  results  with 
habitual  associations  were  even  strikingly  good  when  she  was  asked  two 
or  three  days  afterwards."  In  this  connection  we  may  also  mention  some 
experiments  with  pictures.     Three  days  after  she  had  been  shown  certain 

"These  word- pair  experiments  were  made  with  twelve  different  word- 
pairs  on  five  different  occasions. 


DELIRIUM    PRODUCED   BY   DRUGS  8/ 

pictures  she  was  able  to  pick  out  correctly  the  five  shown  among  twelve. 
And  similar  evidence  of  her  ability  to  retain  impressions  was  seen  from 
day  to  day  when  questions  about  incidents  of  former  interviews  were 
asked.  I  doubt  whether  the  results  would  have  been  the  same  in  alcoholic 
delirium,  for  which  Bonhoeffer  claims  such  a  memory  defect,  although  he 
is  not  very  explicit  about  it.  At  any  rate,  in  view  of  these  results,  it 
seems  very  questionable  whether  we  can  speak  in  this  case  of  a  memory 
defect  independent  of  the  general  clouding  of  consciousness.  It  might  very 
well  be  that  in  alcoholic  deliria,  which  have  many  points  of  relation  with 
Korsakow's  disease,  there  exists  an  independent  memory  defect,  while  this 
is  not  true  in  cases  here  under  consideration.  Finally,  experiments  similar 
to  those  recorded  in  relation  with  the  Korsakow  case  above  mentioned  were 
made,  i.  e.,  the  patient  had  to  tap  every  time  a  three  occurred  in  a  column 
of  figures  read  to  her.  She  omitted  34  per  cent.  These  tests  were  made  at 
two  different  periods — (i)  when  the  delirious  traits  were  more  in  the 
foreground;  (2)  when  the  retardation  was  more  pronounced.  During  the 
former  there  were  present  16.5  per  cent,  omissions,  and  4.8  per  cent,  slow 
reactions;  during  the  latter,  51.5  per  cent,  omissions,  and  4.8  per  cent, 
slow  reactions. 

If  we  summarise  the  clinical  picture  of  these  drug  deliria,  we 
find  in  the  first  place  on  the  physical  side  invariably  a  coated 
tongue,  a  foul  breath,  sordes  at  times.  We  also  find  occasional 
slight  febrile  movements,  sometimes  unsteadiness  of  the  gait, 
increase  of  reflexes,  and  some  slight,  but  quite  inconstant,  tremor, 
The  speech  defect  I  am  inclined  to  attribute  in  part  to  the  bad 
condition  of  the  mouth,  in  part  to  the  clouding  of  consciousness, 
because  it  is  very  striking  how  much  better  these  patients  speak 
when  they  are  aroused.  There  is  no  cyanosis  and  no  flushing; 
on  the  contrary,  the  complexion  of  these  patients  appears  rather 
pasty. 

On  the  mental  side  we  find  first  of  all  a  certain  dulness  and 
hebetude,  so  that  it  is  at  times  difficult  to  arouse  these  patients, 
while  at  the  same  interview  it  may  be  quite  easy;  and  we  have 
repeatedly  noted  that  in  spite  of  a  marked  dulness,  unobtrusive 
noises  may  be  commented  upon.  In  harmony  with  this  dulness 
is  the  fact  that  we  often  find  a  certain  drowsiness  even  in  the 
mildest  cases.     We  shall  later  return  to  this. 

The  most  marked  alteration  is  a  constant  tendency  to  dip 
down  to  a  lower  level  of  consciousness.  This  seems  to  me  a 
more  correct  formulation  than  to  speak  of  an  attention  disorder, 
which  term  is  used,  for  example,  for  the  very  different  alteration 
underlying  flight   of   ideas ;  although   it   is  to  be   expected,   and 


88  DELIRIUM    PRODUCED   BY   DRUGS 

experience  actually  teaches  us,  that  the  lowering  of  conscious- 
ness which  we  here  speak  of  should  lead  to  an  attention 
disorder,  as  a  partial  secondary  manifestation,  which  then,  of 
course,  presents  itself  in  a  very  different  setting  than  that  which 
produces  a  flight  of  ideas.  When  the  consciousness  sinks  to  this 
lower  level  we  have  a  condition  somewhat  akin  to  sleep,  inasmuch 
as  there  is  a  general  dissociation;  spontaneous  trains  of  thought 
arise,  not  connected  with  the  outside  world  or  with  reality,  very 
similar  to  dreams.  At  the  same  time  there  are  hallucinations  of 
various  senses,  more  especially  sight,  hearing,  and  touch.  These 
hallucinations  may  be  produced  artificially  by  rubbing  the  eyes ; 
they  are  also  well  observed  if  the  patient  is  made  to  describe 
pictures  or  to  read.  We  have  seen  that  the  visual  hallucina- 
tions, or  better  the  visual  illusions,  are  in  part  at  least  due  to 
an  indistinctness  of  vision  which  we  have  reason  to  attribute  to 
insufficient  accommodation  and  fixation.  However,  the  essential 
factor  in  the  production  of  these  hallucinations  is  evidently  the 
general  dissociation  for  which  we  find  an  analogy  in  the  hypna- 
gogic hallucinations  and  in  dreams,  and  indeed  it  seems  not 
improbable  that  hallucinations  are  most  frequently  produced  by 
a  dissociation  of  some  kind  or  other. 

It  should  again  be  emphasized  that  this,  we  might  almost  say, 
specific  delirious  tendency  to  dip  down  to  a  lower  level  of  con- 
sciousness, is  but  a  tendency,  and  that  the  patient  can  usually 
be  roused,  often  to  strikingly  good,  connected  activity,  as  was 
shown  in  all  our  patients,  especially  well  in  the  tests  applied  in 
the  case  of  Miss  G.  The  paraphasia  seems  entirely  due  to  the 
lack  of  attention,  the  inability  to  concentrated  activity  as  the 
result  of  the  specific  delirious  alteration,  as  Bonhoeffer  has 
shown. 

The  disorientation  must  also  be  explained  on  the  ground  of 
this  delirious  change,  and  we  have  seen  that  in  these  drug  cases 
a  memory  defect,  independent  of  the  specific  alteration,  can 
probab)"  not  be  made  responsible  for  this  disorientation.  But 
one  thing  should  be  mentioned  in  this  connection.  We  have 
been  struck  with  the  fact  that  delirious  experiences  and  delirious 
interpretations  are  held  with  remarkable  tenacity,  even  during 
the  convalescent  stage,  at  a  time  when  the  patient  is  otherwise 
perfectly  clear,  and  it  is  not  improbable  that  this  peculiar  ten- 


DELIRIUM    PRODUCED   BY   DRUGS  89 

dency,  from  an  explanation  of  which  we  would  refrain,  is  to  a 
great  extent  responsible  for  the  lack  of  correction  which  one 
would  naturally  expect  in  such  patients  who  from  time  to  time 
can  be  aroused  to  a  connected  mental  activity. 

As  we  have  stated,  the  retentive  faculty,  or  the  memory  for 
recent  events  as  such,  is  probably  not  altered  independently,  and 
the  same  may  be  said  in  regard  to  the  memory  for  old  events. 

The  train  of  thought  shows  some  characteristics  which  resem- 
ble thc3e  of  flight  of  ideas,  and  are  due,  as  we  have  said,  to 
the  incidental  attention  disorder,  while  at  other  times  the  con- 
nection is  retained  for  considerable  periods  of  time.  What 
makes  the  utterances  of  the  patient  at  times  so  incomprehen- 
sible to  us  is  not  this  tendency  to  flighty  turns,  but  rather  the 
fact  that  delirious  experiences  are  related  with  which  we  are 
not  acquainted,  and  it  is  further  made  incomprehensible  by  the 
very  frequent  paraphasic  elements. 

The  mood  is  often  indifferent,  but  we  have  seen  in  one  case 
a  certain  euphoria,  again  a  certain  whining  depression,  some 
indications  of  apprehensiveness,  but  never  fear. 

So  far  as  the  motor  side  is  concerned,  we  may  find  a  certain 
restlessness  or  disinclination  to  move,  but  all  this  seems  incidental 
to  the  essential  delirious  alteration :  as  a  rule  it  shows  nothing 
very  pronounced. 

We  will  finally  compare  with  this  picture  that  of  the  alcoholic 
delirium  as  Bonhoeffer  describes  it.  According  to  this  writer, 
this  psychosis  presents  in  80  to  90  per  cent,  of  the  cases  the  fol- 
lowing characteristics.  The  patient  moves  about  a  good  deal, 
and  is  constantly  occupied.  His  face  is  congested,  his  expression 
anxious.  Often  he  shows  marked  fear.  There  is  a  very  pro- 
nounced tremor,  profuse  perspiration.  The  gait  may  be  some- 
what uncertain,  and  there  is  ataxia  of  speech.  We  may  add 
here  that  he  mentions  occasional  eye  muscle  disorders,  which  are, 
however,  slight ;  and,  retrospectively,  the  patients  may  speak  of 
double  vision. 

The  patients  do  not  appear  dull,  and  even  at  the  height  of 
the  delirium  they  can  be  demonstrated  to  students,  and  the 
impression  made  on  them  is  that  the  patient's  manner  of  reaction 
is  not  markedly  different  from  the  normal ;  but  the  examiner 
finds  that  it  takes  some  effort  to  hold  the  patient's  attention.     On 


go  DELIRIUM    PRODUCED   BY   DRUGS 

a  more  careful  examination,  Bonhoeffer  established  the  following. 
It  is  possible  at  any  time  to  force  the  patient  to  a  maximum 
degree  of  attention  which  does  not  differ  from  the  normal.  This 
may  be  shown,  for  example,  by  experiments  with  the  aesthesio- 
meter.  A  conversation  with  the  patient  also  tends  decidedly  to 
raise  his  attention  to  a  certain  level,  but  when  he  is  left  to  himself 
there  is  a  constant  tendency  for  the  attention  to  reach  a  lower 
level,  at  which  time  the  normal  train  of  thought  ceases,  and 
the  arising  ideas  show  a  marked  tendency  to  become  projected, 
as  it  were,  as  hallucinations.  During  an  examination,  when  the 
attention  is  raised  to  a  higher  level,  hallucinations  are  very  few 
or  totally  absent,  and  the  diminished  attention  shows  itself  chiefly 
by  signs  which  are  very  similar  to  those  of  a  normal  inattentive 
state,  such  as  a  paraphasia  similar  to  the  fatigue  paraphasia. 

The  memory  for  old  events  is  not  interfered  with,  and  simple 
calculations  are  done  well,  as  are  all  habitual  tasks ;  but  where  a 
concentration  is  needed,  and  combinatory  efforts  are  required, 
the  patient  fails.  The  retentive  faculty,  however,  is  markedly 
altered.  On  the  ground  of  these  deviations,  Bonhoeffer  ex- 
plains the  disorientation  which  in  these  cases  is  very  marked. 
He  also  mentions  in  this  connection  a  decided  suggestibility  and 
a  marked  tendency  to  confabulation,  which  we  all  know  so  well 
from  our  experience  with  Korsakow  cases.  From  these  con- 
fabulations he  justly  separates  those  which  arise  from  hallucina- 
tions. 

Bonhoeffer  devotes  considerable  space  to  the  hallucinations. 
He  raises  the  question  whether  central  or  peripheral  causes  give 
rise  to  them.  Meynert  has  claimed  that  in  deliria  the  projection 
systems  were  at  fault,  and  others  had  found  various  disorders, 
such  as  amblyopias  (Magnan),  retracted  field  of  vision  (Kruck- 
enberg),  disturbance  of  colour  sensibility  (Galezowsky).  But 
Bonhoeffer  points  out  how,  on  careful  examination,  he  was  unable 
to  find  any  of  these  changes,  except  perhaps  in  colour  vision 
He  is  of  the  opinion  that  peripheral  changes,  if  they  are  of  any 
consequence  at  all,  have  to  be  given  a  very  subordinate  place  in 
the  production  of  hallucinations.  He  mentions  casually  Mendel's 
claim  that  disorders  of  accommodation  have  something  to  do  with 
visual  hallucinations,  but  he  takes  no  position  in  the  matter.  In 
describing  the  many  mistakes  which  such  patients  make  in  read- 


DELIRIUM    PRODUCED   BY   DRUGS  9 1 

ing,  he  says,  however,  that  possibly  the  difficulty  of  convergence 
may  partly  cause  this  disorder,  since  he  obtained  better  reading 
with  monocular  vision.  He  points  out  the  well-known  fact  that 
the  hallucinations  in  delirium  tremens  are  apt  to  be  combined,  so 
that  entire  scenes  are  hallucinated ;  and  he  emphasises  the  fre- 
quency of  the  illusionary  character  of  hallucinations,  which  are, 
after  all,  frequently  a  projection  of  the  patient's  thoughts.  Just 
as  Liepmann,  so  BonhoefTer  found  artificial  hallucinations  pro- 
duced by  pressure  on  the  eyeball,  and  hallucinations  were  also 
produced  by  looking  at  pictures,  or  by  the  reading  tests. 

Now  the  deviations  from  this  picture  are  found  either  in  com- 
plications with  other  psychoses  or  with  epilepsy;  but  what  inter- 
ests us  here  especially  is  his  description  of  the  more  severe  cases. 
Such  patients  are  more  difficult  to  fix ;  finer  tests  cannot  be 
applied.  They  are  duller.  The  motor  excitement  is  coarser, 
more  elementary,  the  cyanosis  is  more  marked,  sweating  and 
anxiety  greater,  the  speech  like  that  in  meningitis.  Eye  muscle 
palsies  are  more  frequent,  as  are  various  other  paralytic  phe- 
nomena.    Such  cases  are  very  apt  to  terminate  fatally. 

If  we  now  compare  the  two  pictures,  that  of  our  deliria,  and 
that  of  the  alcoholic  delirium  as  described  by  BonhoefiFer,  we  find, 
in  the  first  place,  that  that  which  we  have  called  the  specific 
delirious  alteration  is  present  in  both.  The  hallucinations  are 
the  same,  and  here,  as  well  as  there,  it  is  easy  to  produce 
artificially  these  hallucinations ;  they  are  seen  when  pictures  are 
described,  and  the  results  of  the  reading  tests,  e.  g.,  are  practically 
identical. 

But  all  this  we  only  find  by  a  careful  analysis,  whereas  super- 
ficially the  two  states  differ  so  much  that  one  would  never  be 
inclined  to  mistake  the  one  for  the  other.  That  is  due,  in  the 
first  place,  to  the  fact  that  we  find  in  the  alcoholic  delirium  the 
dilatation  of  peripheral  vessels,  and  a  tendency  to  cyanosis,  and 
often  evidence  of  anxiety  or  fear.  The  pulse  shows  more  marked 
alterations  in  alcoholic  deliria.  I  am  inclined  to  attribute  these 
differences  to  the  fact  that  the  alcoholic  delirium  attacks  persons 
who  are  chronic  alcoholics,  and  whose  cardio-vascular  system, 
therefore,  shows  marked  degenerative  changes. 

A  further  difference  is  to  be  found  in  the  tremor,  which  is 
very  marked  in  the  alcoholic  states,  slight  and  inconstant  in  the 
drug  deliria. 


g2  DELIRIUM    PRODUCED   BY  DRUGS 

Above  all,  however,  the  general  responsiveness  of  the  patient 
is  different.  We  have  seen  that,  according  to  Bonhoeffer,  the 
alcoholics  do  not  appear  dull,  and  often  make  a  strikingly  natural 
impression  on  a  casual  observer  so  far  as  their  manner  of  re- 
action to  questions  is  concerned.  In  contra-distinction  to  this, 
we  find  our  patients  presenting  a  certain  dulness  and  hebetude, 
and  it  is  much  more  difficult  to  rouse  them  than  it  is  to  rouse 
alcoholic  patients.  It  was  a  very  natural  supposition  to  think 
that  possibly  this  greater  dulness  might  be  due  to  a  disorder  of 
apprehension  which  was  added  to  the  delirious  alteration,  and 
it  was  for  that  reason  that  the  experiments  on  apprehension  were 
made.  They  showed  us  that  this  is  not  the  case.  One  might, 
perhaps,  say  that  we  happened  to  see  graver  states,  conditions 
of  unusually  great  intensity,  and  that  the  more  marked  conditions 
of  alcoholic  deliria,  such  as  Bonhoeffer  describes,  are  quite 
analogous,  but  are  fatal  only  for  the  reason  that  the  cardio- 
vascular apparatus  is  weak  in  the  alcoholic  conditions.  That 
this  explanation  is  not  sufficient,  is  shown  by  the  marked  ten^ 
dency  to  drowsiness  even  in  our  mildest  case.  Miss  G.  There- 
fore it  cannot  be  merely  a  question  of  intensity,  but  this  hebetude 
seems  to  be  a  special  feature  of  these  deliria.  For  some  reason 
or  other  it  seems  that  although  a  high  level  of  consciousness 
can  be  reached  in  both  kinds  of  cases,  the  tendency  to  sink 
to  lower  levels  is  greater  in  the  drug  than  in  the  alcoholic  deliria. 

To  a  certain  extent  the  fact  that  the  alcoholic  patient  is  con- 
stantly busy  may  depend  upon  this  same  difference.  Whether 
there  is,  in  the  alcoholic  states,  also  a  certain  elementary  motor 
excitability,  I  am  unable  to  say. 

We  have  above  mentioned  the  fact  that  Bonhoeffer  assumes 
the  existence  of  a  memory  defect  for  recent  events  in  alcoholic 
deliria.  Our  experiments  in  the  drug  deliria,  although  they  per- 
haps do  not  allow  a  general  conclusion,  speak  against  such  an 
assumption  for  our  cases.  And  we  have  also  stated  that  it 
would  not  be  improbable  that  alcoholic  conditions  should  present 
such  a  change  though  it  be  absent  in  our  cases,  because  we  know 
how  often  alcoholic  deliria  run  into  conditions  of  Korsakow's 
psychosis. 

There  is  another  symptom  which  Bonhoeffer  mentions,  the 
nature  of  which  is  as  yet  uncertain,  viz.  the  great  tendency  to 


DELIRIUM    PRODUCED   BY   DRUGS  93 

confabulation  which  he  found  in  the  alcoholic  deliria.  The 
"confabulation  "  which  occurred  in  our  cases  appeared  to  be  due 
entirely  to  the  spontaneous  trains  of  thought  which  were  analog- 
ous to  dreams,  and  which  in  part  were  externalised  as  hallucina- 
tions. We  have,  therefore,  throughout  our  descriptions,  spoken 
of  the  patients  "  relating  delirious  experiences."  The  fact  that 
defects  in  the  retentive  faculty  seem  to  have  some  relation  to 
true  confabulation,  would  suggest  the  possibility  that  the  absence 
of  confabulation  and  the  absence  of  a  defect  of  this  nature  were 
related ;  and,  conversely,  the  lack  of  confabulation  might  be  used 
as  an  additional  support  for  the  claim  that  the  retentive  faculty 
is  not  interfered  with. 

We  see,  then,  that  although  superficially  the  alcoholic  and  the 
drug  deliria  are  so  different  that  the  casual  observer  would  never 
be  reminded  of  the  one  by  looking  at  the  other,  they  have 
nevertheless  both  the  same  nucleus,  i.  e.,  the  specific  delirious 
alteration,  which  is  only  marked  by  certain  special  features  char- 
acteristic of  one  or  the  other. 


REMARKS   ON   HABIT-DISORGANIZATIONS   IN   THE 
ESSENTIAL  DETERIORATIONS,  AND  THE  RELA- 
TION OF  DETERIORATION  TO  THE  PSYCHAS- 
THENIC, NEURASTHENIC,  HYSTERICAL  AND 
OTHER  CONSTITUTIONS^ 

By  Adolf  Meyer,  M.D. 

PROFESSOR    OF    PSYCHIATRY,    JOHNS    HOPKINS    UNIVERSITY 

For  years  I  have  been  struck  with  the  frequency,  not  to  say 
uniformity,  with  which  a  number  of  peculiarities  of  make-up 
present  themselves  in  the  history  of  the  cases  which  form  the 
nucleus  of  the  disease-group  which  deserves  the  name  "  essential 
deterioration  process,"  or  "  dementia  praecox,"  in  the  sense  now 
generally  accepted  by  most  alienists  and  perfectly  intelligible  to 
those  who  prefer  not  to  commit  themselves  to  any  special  nosology. 
I  refer  to  those  cases  of  deterioration  in  whom  we  cannot  point  to 
any  satisfactorily  determined  and  experimentally  or  clinically 
demonstrable  constellation  of  outside  factors,  as  we  do  in  alcoholic 
insanity  or  in  general  paralysis.  The  prototype  of  the  disorder 
would  be  those  patients  who,  without  any  special  positive  manifes- 
tations, undergo  an  apathetic  deterioration.  Many  cases  have  some 
positive  symptoms  in  the  form  of  hypochondriacal  additions,  or 
paranoic  developments  with  more  or  less  deficient  systematization, 
or  some  acute  mental  disturbance  of  a  more  or  less  characteristic 
type.  The  term  primary  dementia  is  avoided  and  replaced  by 
essential  dementia,  because  it  has  been  used  in  a  very  promiscuous 
way  so  as  to  include  also  stuporous  disorders  whether  they  belong 
to  this  dementia  group  at  all  or  not. 

The  main-spring  of  investigation  is  the  question  of  establishing 
the  definite  constellations  which  lead  to  any  deviation  under  con- 
sideration, so  that  it  may  be  better  understood  and  avoided  or 
corrected.  The  present  formulae  are  heredity  and  stress,  or 
heredity  and  auto-intoxication,  both  pointing  to  matters  which 
can  be  reached  but  indirectly  and  which  do  not  seem  to  me  to 

*  First  public  formulation  of  the  synthetic  conception  of  dementia 
praecox.    January  3,  1905. 

95 


96  REMARKS   ON    HABIT-DISORGANIZATIONS 

touch  the  working  principles  of  the  disease  which  we  want  to 
understand  and  modify.  Heredity  is  an  extremely  important 
statistical  fact,  and  it  embraces  very  largely  the  excuses  alienists 
have  to  offer  for  theii'  inability  to  cope  with  certain  things.  In 
the  field  of  action  we  are  forced  to  decide  what  we  can  do  in 
the  face  of  heredity.  Stress  undoubtedly  involves  more  of  what 
is  directly  at  issue,  but  it  also  is  an  expression  of  excuse  concern- 
ing a  feature  of  modern  civilization  which  cannot  be  changed  by 
the  physician.  Auto-intoxication  is  the  happy  word  which  has 
all  the  advantages  of  humoral  pathology  and  expresses  the  prin- 
ciple of  many  of  the  methods  of  patching  up  the  disordered  organ- 
ism. It  sounds  like  an  expression  of  accuracy,  but  there  are  no 
direct  methods  of  demonstrating  anything  specific.  It  is  always 
but  part  of  the  disorder  and  the  setting  of  this  disorder  is  what 
is  to  be  established.  Everything  points  to  evidently  rather  com- 
plex constellations,  and  our  aim  must  be  to  pick  out  those  factors 
which  actually  do  the  work. 

During  the  past  years  more  and  more  dissatisfaction  has  devel- 
oped with  Kraepelin's  notion  of  disease-process.  Already  in  my 
review  of  his  fifth  edition  in  1896  I  criticised  the  arbitrariness  of 
calling  dementia  praecox  a  disorder  of  metabolism,  and  Stanley 
Hall  has  lately  given  an  expression  to  very  sensible  criticism  in 
the  following  remarks :  "  The  terms  dementia  prsecox,  insanity  of 
youth,  primary  dementia,  hebephrenia,  and  katatonia  are  all  par- 
tial and  none  of  them  are  entirely  satisfactory.  These  troubles 
do  not  by  any  means  invariably  issue  in  dementia,  but  if  all  did, 
the  processes  that  produced  and  preceded  the  lesions,  and  not  their 
effect,  should  furnish  a  truly  scientific  principle  of  characteriza- 
tion and  nomenclature.  Hegel  said  of  Schelling's  absolute,  as 
many  since  might  have  said  of  Hartmann's  unconscious,  that  it 
was  not  a  true  philosophic  principle,  because  "  all  cows  look  alike 
in  the  dark,"  meaning  that  a  purely  negative  principle  can  never 
be  an  adequate  explanation.  We  may  say  the  same  of  dementia 
prgecox,  which  faintly  suggests  the  propriety  of  giving  to  general 
paresis,  which  almost  always  has  a  fatal  termination,  a  designa- 
tion like  thanatic  dementia,  based  upon  this  fact.  Early  mental 
death  is  a  result  of  the  morbid  processes  we  have  here  to  study, 
but  so  it  is  of  others.  With  senile  dementia  both  the  facts  and 
the  propriety  of  the  name  are  very  different." 


REMARKS   ON    HABIT-DISORGANIZATIONS  97 

Instead  of  suggesting  a  disease-process  which  would  be  apt  to 
befall  any  individual  without  special  predisposition,  and  without 
necessarily  any  heredity,  I  should  propose  for  discussion  the  con- 
cept of  habit-disorders  as  suggestive  of  investigation  of  fact  and 
of  modifiable  and  accessible  factors,  also  not  necessarily  depen- 
dent on  heredity.     I  refer  briefly  to  such  cases  as  the  following: 

Patient  born  in  1874;  was  healthy,  never  robust;  delicate  and  social  as 
a  child.  He  avoided  boys  and  cruel  sports,  talked  little ;  at  about  fourteen 
while  his  disposition  was  very  forgiving  he  became  somewhat  cranky,  went 
little  with  boys,  rather  avoided  girls,  became  jealous  of  his  younger  sister 
and  resented  her  resistance  to  being  bossed.  He  went  to  church  a  great 
deal.  From  the  age  of  seventeen  he  did  not  want  the  sister  around  when 
his  friends  called;  once  he  maltreated  a  young  lady  visitor  by  shoving 
chairs  against  her  so  that  she  fainted.  For  some  time  the  patient  was 
occupied  as  a  clerk,  tinally  he  gave  up  work,  stayed  out  all  night  and  slept 
all  day.  During  a  sickness,  1896-97,  he  was  very  good,  asked  his  younger 
sister  to  pray  for  him  so  he  wouldn't  die,  but  on  his  recovery  he  was  again 
very  ugly.  For  about  a  year  he  stayed  in  a  dark  basement  room  with  the 
curtains  down  so  that  nobody  would  see  him  loafing.  He  resented  the 
bringing  in  of  lights.  About  July,  1897,  he  threatened  his  sister  with  a 
razor;  he  often  threw  bundles  at  the  mother  and  sister  and  often  swore  at 
them  in  the  morning.  He  claimed  that  the  sister  told  people  in  the  street 
he  was  nutty.  The  patient  admits  masturbation  from  the  age  of  nine  or 
ten,  up  to  the  age  of  seventeen,  when  he  fainted  while  playing  hockey;  he 
was  carried  home,  remained  unconscious  twenty  minutes ;  he  claims  not 
to  have  masturbated  since  then,  but  says  he  used  to  think  about  women 
because  he  thought  this  would  diminish  the  nocturnal  emission.  He  ex- 
plained that  his  animosity  against  the  sister  increased  since  one  day  she 
and  some  girls  surprised  him  hugging  a  friend  of  hers.  He  also  did  not 
want  his  sister  to  call  at  a  certain  place  on  account  of  immorality  being 
committed  there.  He  thinks  he  was  commented  on  for  being  out  of  work. 
No  evidence  of  hallucinations,  although  he  thinks  women  called  him  names, 
a  soft-headed  imp,  and  nutty.  Physicians  found  him  depressed,  shame- 
faced. 

The  first  diagnosis  was  sexual  neurasthenia,  with  a  change  of  character 
at  puberty  and  increasing  eccentricity  of  later  years  and  ideas  of  persecu- 
tion and  suspicion  and  irritability  against  family.  Within  about  five  weeks 
after  admission  the  patient  stopped  his  work  at  the  bakery.  He  smelled  a 
bad  smell,  he  never  had  had  it  before  and  didn't  know  whence  it  came. 
He  refused  several  meals,  said  he  heard  some  one  say  that  he  was  sent 
here  for  boarding  and  somebody  whose  name  he  doesn't  want  to  tell 
called  him  an  imp.  In  November  he  developed  stupor  in  which  he  finally 
rolled  up  his  eyeballs,  became  cataleptic,  had  to  be  fed.  He  showed  infiltra- 
'■•'on  of  one  pulmonary  apex.     He   remained  in   a  catatonic  stupor   for  a 

mber  of  months,  and  emerged  from  it  with  a  paranoid  form  of  dementia. 
8 


gS  REMARKS   ON    HABIT-DISORGANIZATIONS 

These  notes  taken  from  an  old  history  do  not  show  as  good 
investigation  as  one  might  desire,  but  show  the  general  trend  of 
observation  which  has  been  repeated  in  many  cases. 

Another  patient  who  is  just  now  under  observation  and  at  pres- 
ent in  stupor  may  serve  as  an  instance : 

C.  H.,  born  1883.  Habit-disorganisation.  Typical  catatonic  deteriora- 
tion at  21. 

Family  History. — Negative,  but  the  father  of  the  patient,  a  night  watch- 
man, has  been  moderately  alcoholic  since  early  life,  occasionally  drinking 
to  excess ;  premature  gray  hair  runs  in  his  family. 

The  patient's  mother  died  at  53,  of  some  obscure  lung  trouble  with 
haemorrhage  just  before  death. 

Personal  History. — The  patient  was  said  to  have  developed  normally 
during  childhood,  though  she  was  looked  upon  as  "  a  nervous  child,"  easily 
startled  and  subject  to  bad  dreams.  She  began  school  at  seven,  was  smart, 
and  applied  herself  well,  but  at  the  age  of  eleven  she  seemed  to  be  failing 
and  was  thought  to  be  studying  too  hard;  she  grew  thin,  seemed  nervous 
and  complained  of  headaches.  When  she  was  twelve  years  old  her  mother 
died,  and  the  patient  was  then  in  such  poor  health  that  her  sister  kept  her 
at  home.  She  was  then  a  very  quiet  girl,  often  complained  of  her  head, 
and  her  sister  says :  "  You  could  see  there  was  something  working  on  her." 
The  patient  had  desired  to  become  a  school  teacher — she  admired  teachers 
because  they  were  neat  and  well  dressed.  This  seems  to  have  been  merely 
a  fancy  which  passed  away  after  she  left  school. 

Her  father's  third  marriage  was  unhappy  through  alcoholism,  the  family 
was  scattered  and  the  patient  lived  with  her  sister.  After  she  began  to 
menstruate  at  fourteen  she  brightened  up,  had  fewer  headaches  and 
seemed  to  be  in  better  health.  Her  sister  never  suspected  any  disordered 
sexual  habits,  but  the  patient  states  that  she  began  to  masturbate  when 
nine  years  old;  and  she  has  probably  continued  up  to  the  present  time 
(masturbation  observed  in  the  hospital)  ;  its  effects  and  whether  or  not  it 
had  anything  to  do  with  the  failure  at  school  and  the  later  difficulty  over 
work,  cannot  be  proved  directly.  The  patient  says  however — "  It  spoiled 
all  my  youth  and  my  life — I  wasn't  like  other  girls — I  didn't  want  to  go 
out  anywhere." 

At  sixteen  she  r.-ent  to  work  in  a  hammock  factory,  but  the  work  was 
considered  too  hard  for  her ;  she  thought  the  noise  gave  her  headache, 
and  she  was  afraid  of  the  machinery.  She  had  attacks  of  nose  bleed  and 
finally  a  diarrhea,  so  that  after  five  months  she  gave  up  this  work.  Seven 
months  later  she  took  a  position  in  a  paper  factory  where  she  worked  for 
a  few  months  until  it  was  burned  down. 

The  patient  was  now  seventeen  years  old  and  about  this  time  she  had 
some  scalp  disease ;  her  hair  fell  out  and  a  patch  of  gray  appeared  on  one 
side  of  her  head.  This  worried  her  intensely;  she  gave  much  attention  to 
covering  up  the  spot,  and  had  the  hair  cut  and  dyed.    She  was  ashamed  to 


REMARKS   ON    HABIT-DISORGANIZATIONS  99 

go  out,  and  when  she  had  the  offer  of  another  position  she  declined  it 
because  she  feared  remarks  would  be  made  about  her  hair.  After  this  she 
remained  at  home  to  look  after  her  father's  house.  It  is  stated  that  she 
did  this  satisfactorily,  but  she  complained  of  headaches  and  sleepiness  in 
the  morning  and  would  lie  in  bed  late;  she  was  alone  most  of  the  time, 
had  no  companions,  and  her  father  worked  at  night  and  slept  through  the 
day.  Her  father  says  she  was  "  a  stuck-up  girl "  and  "  testy  " — especially 
about  her  clothing,  wishing  for  better  than  she  could  afford. 

Her  sister  says  the  patient  never  showed  any  desire  for  the  company  of 
young  men,  and,  in  fact  avoided  them,  and  remarked  that  she  would  never 
marry  as  she  had  seen  enough  of  married  life  (referring  to  her  father's). 
The  patient  says,  however,  that  when  nineteen  she  allowed  two  young  men 
to  take  liberties  with  her,  but  without  complete  connection  as  she  feared 
pregnancy.  She  attended  to  her  religious  duties,  but  showed  no  excessive 
fervor. 

During  her  twentieth  year  she  was  complaining  of  constipation  and  had 
a  "  creepy  sensation  "  in  her  abdomen  which  she  thought  was  due  to  a  tape 
worm.  She  read  quack  pamphlets  and  bought  medicine  from  drug  stores; 
she  developed  hemorrhoids,  became  despondent  over  her  condition,  and 
when  she  was  twenty-one  (January,  1904)  she  went  to  the  Polyclinic 
Hospital  for  operation.  After  the  operation  she  complained  that  the  nurses 
had  neglected  her  and  that  her  bowels  were  full  of  gas;  she  wished  to  be 
taken  home  to  die.  After  ten  days  she  was  removed  to  her  sister's  house, 
where  she  was  very  sensitive  to  noises  and  wished  to  be  quiet.  She  suffered 
from  incontinence  of  the  rectum  for  a  while,  but  this  has  passed  away. 
She  did  not  again  speak  of  the  tape  worm,  but  was  very  nervous  if  her 
bowels  failed  to  move  daily,  and  she  also  expressed  the  idea  that  her 
rectum  was  closing  up.  She  grew  very  thin  and  much  run  down  physically 
after  the  operation. 

Two  months  after  the  operation  she  returned  to  her  father's  house,  and 
with  the  help  of  a  hired  woman,  undertook  to  do  the  housekeeping.  Dur- 
ing March  and  April  she  had  a  severe  attack  of  tonsillitis.  During  the 
summer  she  was  very  quiet,  and  to  the  neighbors  appeared  always  lone- 
some; no  friends  came  in  and  she  didn't  care  to  go  out;  she  suffered 
from  amenorrhea  after  the  operation — she  worried  over  this  and  also  her 
past  sexual  misdeeds  (patient's  statement).  About  this  time  she  thought 
she  would  like  to  study  again  and  be  a  bookkeeper;  she  bought  paper  and 
pens,  put  her  desk  in  order  for  writing  but  nothing  came  of  it.  At  her 
father's  suggestion  she  used  to  ride  on  the  cars  or  sit  in  the  parks ;  she 
apologized  for  spending  money  and  not  working  any.  All  of  this  time 
she  was  sleeping  poorly,  complained  of  her  head  and  was  despondent  about 
herself.  The  neighbors  say  that  her  father  scolded  her  about  the  house- 
work and  she  often  said  "  I  am  a  good  girl "  or  "  I  can  do  nothing  right 
for  him."  The  father  denies  that  he  scolded  her,  but  says  she  got  very 
cranky  through  the  summer  and  without  reason  complained  that  he  hurt 
her  feelings  or  said:  "You  break  my  heart."  Shortly  before  she  left 
home  she  spoke  differently  to  her  father — "  I  have  done  you  wrong,  I  spent 


lOO  REMARKS   ON    HABIT-DISORGANIZATIONS 

your  money,  you  worked  fifteen  months  for  nothing,  you  have  no  good 
clothes,"  etc.  She  began  to  be  afraid  to  stay  alone  at  night,  and  a  week 
before  her  admission  at  a  party  in  her  sister's  house,  she  remarked — 
^'Everybody  is  looking  at  me,  I  don't  know  why."  A  few  days  before  she 
left  home  she  said — "  I  have  been  sick  a  long  time  and  thought  I  was  going 
to  die,  but  now  I  think  Tom  (brother)  is  going  to  get  sick  and  die."  One 
morning  she  prepared  breakfast,  but  would  not  eat  because  she  had  to  pray 
for  everybody  first — later  she  ate  breakfast.    Then  followed  queer  acts. 

On  October  i,  1904,  she  went  to  see  the  priest  and  that  night  she  was 
heard  by  the  neighbors  praying.  The  next  morning  she  went  to  church 
dressed  untidily,  left  candles  burning  in  her  room  and  poured  kerosene 
oil  on  the  steps  for  holy  water.  That  day  she  threw  some  things  out  the 
window  because  a  curse  had  been  put  on  her  by  her  father  and  she  didn't 
wish  him  to  have  anything.  That  night,  October  2,  she  went  at  ten  o'clock 
to  where  her  father  was  at  work,  said  she  wished  to  see  a  priest  and  spoke 
of  having  neglected  her  church  while  she  had  been  sick.  Her  father 
accompanied  her  part  of  the  way  home,  where  she  later  disarranged  the 
furniture  and  other  things,  and  at  midnight  left  the  house  in  her  night- 
dress ;  she  was  found  by  a  policeman  kneeling  in  front  of  the  church.  She 
told  the  officer  correctly  where  she  lived  and  returned  home  with  him 
praying  all  the  while.  Later,  when  an  ambulance  came  to  take  her  to 
Bellevue,  she  said — "  I  am  a  good  girl — my  mother  is  dead — it's  all  my 
father's  fault." 

At  Bellevue  she  said^ — "  /  hear  angels  telling  me  how  to  pray  when  I  lose 
my  thoughts — sisters  and  nuns  are  around  me  here  to  save  and  purify  the 
world,"  etc.  At  times  she  sang  and  rhymed,  would  jump  up  suddenly  and 
gesticulate  wildly  and  then  fall  back  on  her  pillow  as  if  asleep ;  she  ad- 
mitted that  she  heard  voices,  and  while  in  Bellevue  she  held  her  right  arm 
under  a  stream  of  hot  water  and  sustained  a  severe  burn;  she  later  ex- 
plained that  she  did  this  in  order  to  save  the  world. 

She  came  to  the  State  Hospital  October  10,  1904.  On  the  ward,  during 
the  bath  and  in  bed  she  presented  a  state  of  beatitude,  walked  with  her 
eyes  closed,  prayed  and  sang,  with  slow  gestures  and  theatrical  pathos, 
responded  in  a  monotonous,  unctuous  manner — passed  from  smiles  to  tears, 
assisted  little  when  cared  for  by  the  nurses,  even  wet  and  soiled  her  bed, 
and  when  asked  why  she  did  so  replied :  "  Although  I'm  22  years  old  I 
have  been  transformed  from  a  big  girl  into  a  small  baby."  Why?  "Well 
the  Lord  said  I  was  too  pure  to  be  a  woman,  and  in  order  to  save  the 
world  I  had  to  be  once  more  a  baby." 

Her  arm  was  slightly  resistive,  remained  elevated  from  ^2  to  i  minute, 
then  dropped  quickly  and  relaxed.  Her  productions  were  a  monotonous 
and  empty  religious  jumble,  slowly  produced  in  speech  and  song  or  mere 
whispers  with  devotional  gestures,  closed  eyes  and  a  saintly  sufferer's 
mien,  interrupted  by  some  queer  acts.  The  following  is  a  sample  of  her 
spontaneous  rtterances :  "  I  believe  in  the  Lord  God — Father  Almighty  and 
St.  Joseph — Sweet  Virgin  Mary  pray  for  us — Almighty  God,  have  mercy 
on  me — forgive  me  my  sins — grant  me  remission  of  all  my  sins   (crossing 


REMARKS   ON    HABIT-DISORGANIZATIONS  lOI 

herself).  .  .  .  Divine  Catholic  world — now  and  forever — A-amen — 
glory  be  to  the  Father,  Son  and  Holy  Ghost,  as  it  was  in  the  beginning 
.  .  .  Mary  is  the  branch  and  Jesus  the  flower — A-amen — at  least  you, 
my  friend,  sweet  Jesus,  have  pity  on  me  (long  pause)  that  he  may  lead  us 
into  a  more  pure,  good,  Irish — divine — Catholic  world."  She  then  folded 
and  unfolded  the  counterpane,  continued  to  whisper  prayers,  held  her  hand 
before  her  face  and  licked  it  with  her  tongue.  She  had  a  correct  appre- 
ciation of  things,  touched  the  physician  accidentally,  and  said — "  Excuse 
me,  doctor."  She  noticed  the  laughing  outside  and  said :  "  I  don't  need 
them — I  don't  want  them  to  be  laughing  at  me  out  there — I  want  to  be  left 
alone  to  say  my  prayers  in  peace  and  quietness  .  .  .  now  let  me  sleep 
in  peace  and  quietness,  for  I  am  about  exhausted." 

What  is  the  matter,  have  you  any  trouble ?  "I  have  been  sick,  I  guess — 
yes — oh,  for  four  years.  ...  It  came  from  my  stomach,  I  had  stomach 
trouble — I  had  bowel  trouble — I  had  chest  trouble — throat  trouble — face 
trouble — teeth  trouble — nose  trouble — eye  trouble — compound  or  complex 
for  me — head  trouble — brain  trouble  and  all  the  quarrelling — father  squab- 
bling and  scolding  all  the  time — he  sent  me  out  for  bug  medicine,  and  may 
Almighty  God  give  that  medicine  to  the  one  who  started  this  business — 
this  devil's  island."  Are  you  sad?  "I  was  sad  but  not  now,  I'm  happy 
now."  Are  you  afraid?  "No  more,  I  was  dreadfully — of  everything  on 
earth — for  lo  years,  since  my  mother  died."  Afraid  of  what?  "Every- 
thing, no  one  would  look  at  me  or  talk  to  me — only  about  me — they  said 
everything  bad  about  me,  that  I  was  a  bad  girl,  but  I  was  pure."  She 
made  some  reference  to  her  gray  hair,  and  when  asked  to  explain,  said: 
"  Part  of  my  hair  is  gray — that's  what  near  made  the  world  come  to  an 
end — they  all  laughed  at  me,  talked  about  me,  and  even  drew  up  a  play 
about  me  called  Devil's  Island."  She  referred  to  the  other  people  on  the 
ward  as  "  all  the  good,  true  souls — I  don't  know  whether  they  are  going 
to  save  me  or  whether  I  am  going  to  save  them." 

All  this  shows  numerous,  at  times  senseless  moralising  and  ecclesiastic 
reiterations  with  the  undercurrent  of  salvation  achieved  or  longed  for — 
for  herself  and  the  world;  no  true  flight  nor  a  dearth  of  ideas  in  the  full 
enumeration  of  her  troubles  but  again  evidence  of  stereotypy  of  form, 
utterance  in  contrasts  and  reference  to  Devil's  Island,  quarrels  at  home, 
being  laughed  at,  etc.  "  I  had  worms  and  the  worms  had  me." — "  I  want 
to  save  everybody  and  everybody  wants  to  save  me." — "  I  went  out  for 
bug  medicine  and  the  bugs  took  my  way — I  lost  my  way." — "  You're  Mr. 
Tiffany " — an  interpretation  of  Dr.  M.'s  identity ;  also,  when  asked  her 
own  name  she  replied:  "Baby  Chadwick  of  the  whole  world — Divine — 
Irish — Catholic  world — Amen." 

Physical  examination  showed  increased  tendon  reflexes ;  fine  tremor  of 
the  tongue,  face  and  fingers.  Pupils  somewhat  variable  in  size,  but  react 
normally;  a  bright  red  line  appears  when  the  skin  is  marked,  and  once 
when  excited  (screaming)  her  whole  body  flushed  deeply;  feet  and  hands 
cool  and  moist.  Pulse  high  (i  10-120),  small  and  soft  at  the  wrist;  a  large 
burn  on  the  right  arm ;  slight  retroversion  of  the  uterus ;  masturbation 


I02  REMARKS   ON    HABIT-DISORGANIZATIONS 

observed.  Subjective  sensations  of  pins  and  needles  through  her  body, 
"  Catholic  electricity,"  and  a  feeling  as  if  she  -were  "  in  power." 

The  first  night  in  the  hospital  she  was  sleepless — singing,  praying, 
taking  off  her  night  dress,  kneeling  on  the  floor.  Once  she  assaulted  a 
nurse,  jumped  out  of  bed,  ran  to  the  window,  shouting:  "Mr.  Sullivan, 
Mr.  Sullivan,  save  me,  save  me,  I'm  lost."  The  following  morning  her 
explanation  of  this  episode  was  as  follows :  "  Everything  went  wrong  last 
night,  good,  pure,  true  and  holy  doctor — I  led  you  astray,"  etc.  A  similar 
outbreak  of  excitement  occurred  during  the  physical  examination  and 
again  the  following  night.  After  this  she  slept  and  claimed  to  feel  better. 
She  had  put  her  arm  under  the  faucet  to  save  the  world — "  Good,  kind. 
Catholic  doctor,  I  gave  up  my  whole  right  arm."  She  then  claimed  the 
nurse  was  the  whole  cause  of  the  trouble  and  was  irritable  towards  her. 
She  later  excused  her  actions  by  — "  I  was  sick  in  my  head,  dizziness  in  my 
head — excuse  me,  doctor,  I  was  out  of  my  head  and  knew  not  what  I  was 
doing." 

She  had  an  attack  of  diarrhea  just  after  admission,  which  subsided  in 
four  days,  and  her  pulse  also  declined  gradually  to  about  90. 

Examination  nine  days  after  admission  found  her  quieter,  that  is,  with 
less  spontaneity  in  productions,  but  she  was  still  in  an  ecstatic,  dreamlike 
but  not  dreamy  state.  She  gave  vague  accounts  of  hallucinations,  of 
"  thoughts  "  from  God  and  of  commands  to  scald  her  arm,  of  being  "  in 
power "  (pins  and  needles)  ;  she  explained  that  she  had  called  herself 
"  Baby  Chadwick  "  because  that's  what  they  had  pinned  on  her  blue  dress 
in  Bellevue.  She  was  correctly  oriented  as  to  place  and  nearly  so  as  to 
time.  Still  called  Dr.  M.  "  Mr.  T,"  though  she  could  give  his  name 
correctly.  She  showed  a  remarkably  clear  grasp  on  the  remote  past,  but 
her  statements  in  regard  to  more  recent  events  were  colored  by  her  peculiar 
trend,  e.  g.,  in  regard  to  her  admission  she  spoke'  of  being  taken  to  the 
"  sanctuary,"  "  where  my  bowels  moved  and  my  water  passed  from  me — I 
call  it  that  because  I  suppose  Jesus  did  the  same  things  I  did."  She  spoke 
of  the  bath,  as  where  she  had  again  been  baptized.  Her  attention  was 
variable,  but  retention  was  good.  A  newspaper  account  of  a  railroad  acci- 
dent was  correctly  read,  but  then  queerly  elaborated — "  It  ran  over  my 
arm,"  etc.  She  gave  the  Lord's  prayer,  repeatedly  making  an  omission 
which  she  did  not  appreciate.  Calculation  was  erratic,  at  times  giving 
random  replies. 

Her  own  description  of  her  condition  was  very  striking,  e.  g.,  when 
asked  if  she  was  sick  she  replied :  "  I  was,  but  not  now,  my  head  was  bad." 

Were  you  out  of  your  head?  "No,  doctor,  I  had  all  my  senses  and 
faculties,  but  I  was  senseless."  When  asked  why  she  had  spat  at  the  physi- 
cian she  again  spoke  of  being  "  in  power,"  and  said :  "  There  is  a  power 
over  us  and  amongst  all  of  us — a  holy  power — it  may  have  been  an  electric 
power — I  had  all  my  senses  and  wasn't  out  of  my  head — it  was  a  derange- 
ment of  the  mind  that  came  over  me."  When  asked  to  explain  this  said : 
"Well,  it  seems  as  if  the  world  was  coming  to  an  end' — the  20th  century 
coming  or  some  turn." 


REMARKS   ON    HABIT-DISORGANIZATIONS  IO3 

At  the  end  of  two  weeks  she  rarely  spoke  spontaneously,  but  lay  quietly 
in  bed,  showed  some  waxy  rigidity  in  the  limbs,  kept  given  positions  and 
vras  slow  and  constrained  in  all  her  movements.  She  gave  strange  account- 
ing for  her  actions,  e.  g.,  during  an  interview  she  would  rise  slowly  from 
her  chair,  explaining  that  she  did  so  "  to  be  with  the  nurse  " — "  to  try  to 
be  good,"  etc. 

Why  have  you  been  standing?    "To  try  to  live." 

Why  do  you  hold  up  your  arm?    "  For  peace." 

At  the  end  of  a  month  she  had  passed  into  a  pseudo-stuporous  state, 
was  more  rigid  and  resistive,  did  not  always  respond,  though  tears  would 
often  roll  down  her  cheeks.  She  held  saliva  and  required  spoon  feeding. 
She  brightened  up  a  little  at  the  beginning  of  a  course  of  catharsis  but 
soon  relapsed.  Occasionally  she  was  restless  at  night  and  once  when  asked 
where  she  wished  to  go,  said :  "  To  fight  for  my  life — fight — fight — out — out 
— out  away  from  here  .  .  .  follow  me — follow  me — I  am  going  to  serve  the 
American  Army  and  Navy  with  my  life." 

During  1905  the  patient  still  maintained  constrained  attitudes ;  she  sat 
the  entire  day  with  her  hands  on  her  knees,  her  head  bent  somewhat  for- 
ward and  tilted  to  one  side;  she  rarely  moved  unless  urged  to  do  so;  she 
was  profoundly  apathetic  and  careless  about  her  personal  habits.  As  a 
rule  she  answered  very  few  questions  and  then  gave  mostly  stereotyped 
pious  phrases.  Often  tears  were  seen  streaming  down  her  cheeks.  She 
held  saliva  in  her  mouth,  sometimes  refused  food,  again  ate  ravenously. 
Frequently  she  would  burst  out  laughing  or  smile  without  any  cause. 

Since  1906  her  behavior  has  shown  little  change ;  as  a  rule  she  is  mute, 
lacks  all  initiative  and  is  untidy  in  her  habits.  There  is  still  a  tendency 
to  maintain  given  positions,  and  slight  muscular  stiffness  is  encountered 
in  the  limbs. 

In  Other  words  we  have  here  again  a  patient  with  precocious 
sexual  instincts,  inefficiency  at  school,  and  later  in  factory  work, 
neurasthenoid  symptom — complex  with  head  and  intestinal  symp- 
toms, growing  seclusiveness,  marked  disorder  of  intestinal  habits, 
amenorrhea,  and  finally  development  of  a  peculiar  tantrum.  With- 
out any  of  the  causes  which  are  sufficient  to  bring  about  a  similar 
dream-like  phantastic  state,  in  a  form  quite  different  from  a  de- 
lirium, or  manic-depressive  attack,  or  anxiety  psychosis,  or  hyster- 
ical dream  state,  in  a  condition  which  was  compatible  with  normal 
orientation  and  grasp  on  the  environment,  an  odd  state  of  longing 
for  an  enjoyment  of  salvation  with  a  strange  mystic-allegoric 
trend  of  action,  interpretation  and  notions  developed,  probably 
most  like  a  hysterical  dream-state,  but  with  much  more  deficiency 
in  corrigible  foundation  and  relation  to  things  as  they  are.  Occa- 
sionally there  are  acts  of  perplexity ;  the  patient  claims  to  hear 


I04  REMARKS   ON    HABIT-DISORGANIZATIONS 

angels  telling  her  to  pray  "  when  she  loses  her  thoughts  " ;  strange 
sensations  make  her  feel  "in  power,"  telephone-feeling — symptoms 
of  a  strange  phantastic  character.  Matters  which  may  come  up 
in  dreams,  in  deliria,  come  up  in  a  relatively  clear  state  of  mind. 
Unreality  and  absurdity  without  any  evidence  of  sufficient  cor- 
rectives by  sound  habits  of  thought  dominate  the  tantrum.  There 
is  a  feeling  of  deficiency  or  queerness,  clearly  in  contrast  with  the 
manic-depressive  feeling  of  mere  difficulty  and  impotence.  The 
emotional  reaction  is  as  erratic  and  poorly  controlled  as  the  intel- 
lectual appreciation,  the  ensuing  impulses  and  motor  states  stamped 
with  a  certain  monotony,  and  evidence  of  cataleptic  states. 

The  attacks  usually  take  the  form  of  a  tantrum  of  some  sort, 
partly  characteristic  in  itself  or  through  the  foundation  on  which 
it  grows.  A  large  proportion  stumble  over  the  interpretation  of 
abnormal  sensations,  or  over  sexual  experiences. 

Instead  of  merely  appealing  to  cortex  changes  of  obscure  cor- 
relation, or  to  equally  obscure  auto-intoxications,  or  to  arrest  of 
development,  I  refer  to  the  disharmony  of  habits,  disharmony  of 
those  regulations  which  shape  a  well-balanced  economy :  The  in- 
testinal and  circulatory  functions,  the  sexual  life,  and  above  all  the 
trend  of  interests  depending  in  its  integrity  and  efficiency  on  a  cer- 
tain equilibration.  I  have  been  led  in  my  thought  by  the  analogy  in 
the  development  of  morphological  phenomena.  Roux  has  shown 
by  his  experiments  on  the  mechanics  of  development  how  each 
part  of  the  organism  has  a  certain  dynamic  and  morphogenic  pos- 
sibility, but  that  in  many  points  the  shaping  to  a  final  perfection 
depends  on  regulation  of  the  balance  of  the  simultaneously  grow- 
ing other  organs  and  their  functions.  Deficient  growth  or  preco- 
cious growth  of  an  organ  disturbs  these  regulations,  and  the  nec- 
essary result  is  a  disharmony  and  every  plus  is  apt  to  be  held 
up  by  some  minus  in  another  direction.  This  same  principle  is 
eminently  valid  in  functional  life,  and  especially  valuable  in  the 
most  complex  of  biological  regulations — those  of  mentation.  Here 
a  veritably  practical  and  critical  presentation  of  the  early  work 
of  James  has  very  justly  pointed  to  habits  as  a  unit  of  observa- 
tion and  biological  interest.  And  it  will  be  our  duty  to  define  in 
actual  cases  what  sets  of  habits  we  find  interwoven  and  with  what 
effect.  This  directs  the  attention  to  the  investigation  of  matters 
which  are  open  to  influence  in  education,  and  to  a  more  rational 


REMARKS   ON    HABIT-DISORGANIZATIONS  IO5 

management  of  dementia  praecox,  as  well  as  many  other  mental 
disorders ;  and  habit-disorder  is  to  be  treated  by  habit-training, 
not  by  vague  encouragement  and  excessive  protection  and  mere 
fighting  of  incidental  disorders.  To  be  sure  all  incidental  dis- 
orders, such  as  the  phenomena  usually  lumped  together  as  auto- 
intoxication, must  be  corrected  as  far  as  possible,  and  their  cor- 
rection gives  us  a  vantage  ground  on  which  to  begin  and  promote 
the  more  fundamental  principle — that  of  habit-training.  And  in 
cases  where  we  see  disorders  developing,  whether  on  ground  of 
heredity  or  not,  it  is  this  issue  which  guides  us  in  the  concrete 
plan  of  teaching  and  prevention.  And  since  the  other  elements 
which  are  apt  to  figure  in  our  presentations  of  etiology,  nosology 
and  pathology  are  much  more  hazy,  it  is  much  more  satisfactory 
to  come  out  frankly  with  a  statement  that  we  wish  to  make  dis- 
tinctions of  various  types  of  habit-disorganization,  to  study  the 
working  of  the  various  sets  of  activities  and  habits  in  the  patient, 
determine  their  relative  values  by  accurate  observation  coming  up 
to  the  mark  of  the  experiment,  and  shaping  our  therapeutic  meas- 
ures in  accord  with  these  principles.  This  naturally  does  not 
exclude  in  any  possible  way  the  consideration  of  the  factors  of 
heredity,  and  the  disorders  of  this  or  that  organ,  but,  on  the  con- 
trary, gives  every  manageable  part  its  working  chance. 

In  viewing  the  cases  of  insanity  which  are  not  plainly  of  exoge- 
nous origin,  we  find  certain  types  of  combinations  of  a  more  or 
less  distinct  symptom-picture,  course  and  outcome.  In  "  An  At- 
tempt at  Analysis  of  the  Neurotic  Constitution,"  published  1903  as 
a  contribution  to  the  commemorative  number  of  G.  Stanley  Hall's 
journal,  I  specified  and  briefly  characterized  the  following  types : 
(i)  The  psychasthenic  with  its  feeling  of  insufficiency,  misplaced 
tension,  apprehension,  phobias  and  impulses,  practically  as  out- 
lined by  Janet;  (2)  the  neurasthenic  with  great  fatigability  and 
irritability;  (3)  the  hypochondriacal  with  feelings  of  organic  in- 
sufficiency ;  (4)  the  hysterical  with  dissociations  and  the  charac- 
teristic interference  by  undercurrents  of  more  or  less  emotionally 
tinged  concepts  or  thought-habits;  (5)  the  epileptic,  fundamentally 
an  abnormal  neuromotor  reaction  type.  And  finally,  a  number  of 
groups  more  closely  approaching  a  certain  definite  mental  derange- 
ment: (a)  The  unresistive  (responding  easily  to  fever,  to  intoxi- 
cation) ;  (b)  the  manic-depressive  make-up,  described  by  Hecker; 


I06  REMARKS   ON    HABIT-DISORGANIZATIONS 

(c)  the  paranoic  type  with  its  tendency  to  suspicions,  interpreta- 
tions, with  or  without  aggressiveness,  and  finally,  (d)  the  actual 
deterioration  type,  which  I  describe  as  follows : 

In  cases  of  dementia  praecox  we  find  over  and  over  an  account 
of  frequently  exemplary  childhood,  but  a  gradual  change  in  the 
period  of  emancipation.  Close  investigation  shows,  however, 
often  that  the  exemplary  child  was  exemplary  under  a  rather 
inadequate  ideal,  an  example  of  goodness  and  meekness  rather 
than  of  strength  and  determination,  with  a  tendency  to  keep  good 
in  order  to  avoid  frights  and  struggles.  Later  religious  interest 
may  become  very  vivid,  but  also  largely  in  form;  a  certain  dis- 
connection of  thought,  unaccountable  whims  make  their  appear- 
ance, and  deficient  control  in  matters  of  ethics  and  judgment;  at 
home  irritability  shows  itself,  often  wrapped  up  in  moralizing 
about  the  easy-going  life  of  brothers  and  sisters;  sensitiveness  to 
allusions  of  pleasure,  health,  etc.,  drive  the  patient  into  seclusion. 
Headaches,  freaky  appetite,  general  malaise,  hypochondriacal  com- 
plaints about  the  heart,  etc.,  unsteadiness  of  occupation  and  ineffi- 
ciency, day  dreaming,  and  utterly  immature  philosophizing,  and 
above  all,  loss  of  directive  energy  and  initiative  without  obvious 
cause,  such  as  well-founded  preoccupations,  except  the  inefficient 
application  to  actuality.  All  these  traits  may  be  transient,  but  are 
usually  not  mere  "  neurasthenia,"  but  the  beginning  of  a  deteriora- 
tion, more  and  more  marked  by  indifference  in  the  emotional  life 
and  ambitions,  and  a  peculiar  fragmentary  type  of  attention,  with 
all  the  transitions  to  the  apathetic  state  of  terminal  dementia. 

I  am  inclined  to  put  the  emphasis  on  a  deficiency  of  critical  and 
consecutive  thought-habits,  with  a  prevalence  of  interest  in  the 
phantastic,  mystic,  religious  and  unreal,  owing  to  deficiency  in 
working  interests,  which  would  dovetail  with  the  progressive 
active  course  of  the  world. 

This  scheme  is  open  to  many  supplements,  and  it  will  be  an 
especially  grateful  task  to  push  the  inquiry  of  individual  make-up 
along  the  lines  of  changes  of  constitutional  make-up  due  to  trau- 
matism, to  toxic  influences,  to  sexual  insufficiency,  to  the  preva- 
lence of  certain  thought-habits  (especially  the  estrangement  with 
actuality  in  the  form  of  occultism),  and  under  the  influence  of 
the  period  of  involution  and  senescence. 

Clinically  it  is  rather  remarkable  that  the  above  types  keep 


REMARKS   ON    HABIT-DISORGANIZATIONS  lO/ 

fairly  distinct.  We  find  in  many  presentations  of  neurasthenia, 
hysteria,  etc.,  the  comfortable  and  probably  usually  true  state- 
ment that  simple  habit-disorganization  of  most  of  the  above  types 
has  nothing  to  do  with  insanity,  and  there  need  be  little  fear  of 
its  coming  on.  Experience  justifies  this  comforting  remark  to  a 
large  extent.  There  is  also  a  certain  justification  in  the  strong 
efiForts  of  many  writers  to  discourage  the  uncritical  intermingling 
of  these  types,  in  terms  like  hystero-epilepsy,  hystero-melancholia. 
And  Kraepelin's  effort  of  taking  most  of  the  endogenous  deteriora- 
tion forms  into  his  group  of  dementia  praecox  is  in  part  a  similar 
attempt  at  being  systematic.  If  we  take  dementia  praecox  to  be 
a  disease  by  itself  which  might  befall  any  one,  it  is  not  very 
intelligible ;  we  emphasize  in  dementia  praecox  the  fact  of 
looseness  of  judgment  and  consequential  thought  with  prepon- 
derance of  habits  of  the  unreal,  with  either  a  gradual  deteriora- 
tion of  interests,  or  more  acute  collapses  over  difficulties  to  which 
the  individual  is  not  equal.  We  might  say  that  the  psychasthenic, 
as  a  rule,  is  not  of  this  type,  the  hysterical  is  more  organized,  the 
true  neurasthenic  the  same,  also  the  manic-depressive  type,  and 
in  part  the  paranoic.  In  the  epileptic,  deterioration  may  occur  in 
the  form  of  epileptic  deterioration,  or  as  a  typical  dementia  praecox 
superceding  epilepsy.  Psychasthenics  are  apt  to  deteriorate  to 
the  level  of  lack  of  initiative  of  the  dementia  praecox  class. 
Whether  plainly  and  simply  hysterical  individuals  are  apt  to 
develop  the  characteristics  of  the  dementia  praecox  complex  is 
denied  by  some,  while  Janet  claims  that  every  year  a  few  of  their 
cases  of  hysteria  have  to  be  transferred  to  the  service  of  mental 
disease  on  account  of  deterioration.  Many  cases  of  dementia 
praecox  begin  with  hysterical  symptoms.  The  whole  symptoma- 
tology of  catatonia  shows  so  many  traits  in  common  with  the 
phenomena  of  hysteria  and  of  hypnotism  that  certain  French 
authors  look  upon  it  as  a  hysteriform  psychosis.  I  should  like  to 
refer  to  a  very  interesting  case  that  was  looked  upon  as  dementia 
praecox  notwithstanding  a  plainly  hysterical  onset  after  confine- 
ment, but  which  recovered  completely,  and  in  whom  investigation 
showed  that  there  were  none  of  the  manifest  and  plain  antecedents 
of  dementia  praecox.  This  is  a  patient  whom  I  turned  over  to  a 
pupil  of  a  prominent  worker  on  hysteria,  who  declined  recognizing 
in  it  the  hysterical  complex  and  gave  a  verdict  of  dementia  praecox 


I08  REMARKS   ON    HABIT-DISORGANIZATIONS 

without  analysis  of  the  facts.  I  might  furnish  other  instances  of 
tantrums  allied  to  dementia  prsecox  developing  without  well- 
marked  antecedents  of  deficiency,  and  on  such  ground  taking  a 
favorable  course. 

Looking  over  the  whole  field  we  see  in  dementia  prsecox  above 
all  the  psychic  deficiency  to  meet  actuality,  a  tendency  to  unreality, 
to  the  mystic,  common  enough  outside  of  dementia  precox,  but 
here  combined  with  the  deficiency  of  judgment  and  habit  due  to 
the  undermining  effects  of  other  disorganizations  of  mental  and 
organic  habits.  The  prevalence  of  defect  in  the  habits  of  the 
reproductive  zone  is  most  striking,  especially  in  walks  of  life 
where  the  difficulties  are  less  likely  to  be  swallowed  up  by  the 
muddy  stream  of  open  immorality,  where  conventional  morality 
and  frequently  excessive  observation  of  superficial  morality 
create  remarkable  pictures  which  figure  very  well  as  classical 
representatives  of  the  disorder. 

Looking  back  over  the  merits  of  the  point  of  view  taken,  I 
should  like  to  say  in  its  favor  that  it  tends  towards  putting  into 
the  center  of  nosological  and  pathological  attention  the  only  fac- 
tors which  can  be  of  practical  importance  in  the  management  of 
these  disorders. 

In  the  general  discussion  on  the  paragraphs  of  etiology,  these 
points  of  disharmonious  development  are  put  down  as  the  product 
of  mere  fatal  constitutional  defect,  the  result  of  some  statistical 
fate,  reminding  one  of  the  dogma  of  infant  damnation,  training 
in  the  students  a  habit  of  moving  in  generalities  and  fostering  a 
disinclination  to  going  into  the  study  of  the  actual  case ;  the  age 
at  which  the  disease  occurs,  the  sex,  the  climate,  the  stress,  and  a 
lot  of  other  things  from  which  no  individual  can  escape  are  re- 
hearsed, and  with  a  sort  of  disdain  for  the  actual  pathological  and 
morphological  value  of  the  directly  important  things,  which  are 
relegated  to  casual  remarks  under  therapeutics,  where  we  find 
warnings  against  masturbation,  against  overactivity  of  the  artistic 
imagination,  etc. 

Didactically  and  from  the  point  of  view  of  keeping  one's  self 
in  the  frame  of  soundest  activity,  it  seems  to  me  very  desirable 
that  these  factors,  the  working  factors  of  the  disease,  should  be 
utilized  to  the  utmost ;  and,  in  the  face  of  the  inevitable  criticism 
that  these  are  old  matters  which  everybody  knows  and  that  what 


REMARKS   ON    HABIT-DISORGANIZATIONS  IO9 

is  wanted  is  some  absolutely  new  discoveries,  we  need  no  longer 
be  afraid  of  conjuring  up  a  moralizing  psychiatry  if  we  hold  each 
other  down  to  speaking  of  the  facts  as  they  occur  in  actual  cases, 
and  as  they  are  not  only  conceivable  but  actually  at  zvork.  There 
is  hardly  anything  of  which  it  is  not  possible  to  say  that  the 
ancient  Hindoos,  the  Greeks  and  our  forefathers  thought  exactly 
the  same  way,  and  that  we  do  those  things  in  every-day  life.  Un- 
fortunately, speculation  too  easily  solves  many  puzzles  which  it 
takes  many  years  of  experimental  and  clinical  work  to  put  on  a 
safe  working  basis.  It  is,  nevertheless,  concrete  work  that  has  to 
be  done  and  will  prove  the  soundest  ground  for  stimulating  the 
interest  of  the  physician  in  his  work  of  understanding  and  modify- 
ing cases,  and  in  forming  sufficiently  definite  problems  in  what 
otherwise  would  be  a  mess  of  arbitrary  creations  of  nosology. 


CONSTITUTIONAL   FACTORS    IN   THE   DEMENTIA 

PRECOX  GROUPS 

By  Dr.  August  Hoch 

PSYCHIATRIC  INSTITUTE,   N.  Y.   STATE   HOSPITALS 

Among  the  present  problems  of  psychiatry  the  study  of  dementia 
praecox  is  perhaps  that  which  excites  the  most  general  interest. 
It  is  more  particularly  the  fundamental  nature  of  the  disorder 
which  is  discussed,  and  in  regard  to  which  the  views  diverge. 
The  claim  is  often  made  that  we  have  in  dementia  praecox  an 
organic  brain  disease  similar  to  general  paralysis  or  the  other 
typically  organic  disorders.  There  is  no  doubt  that  we  find  in  the 
central  nervous  system  in  cases  of  this  group  structural  changes ; 
some  of  them  are  evidently  not  related  to  the  disorder,  while  there 
are  others  which  probably  form  a  part  of  the  process,  although 
we  do  not  yet  clearly  understand  under  what  conditions  they  are 
found  nor  what  their  real  significance  is.  While  these  findings, 
upon  which  rests  the  claim  that  dementia  praecox  is  an  organic 
disorder  in  the  same  sense  as  is  general  paralysis,  cannot  be 
neglected,  and  represent  a  most  important  field  for  research,  there 
is  another  set  of  data  furnished  by  an  analysis  of  the  constitu- 
tional factors  in  these  cases,  of  the  development  of  the  symptoms, 
their  nature,  and  their  relationship  among  each  other — data  which 
would  seem  to  show  that,  granted  all  the  findings  of  an  anatomical 
and  perhaps  chemical  nature,  dementia  prsecox  is  after  all  not  a 
condition  which  can  be  placed  side  by  side  with  the  plainly  organic 
diseases,  such  as  general  paralysis.  Instead  of  going  into  a  theo- 
retical discussion  as  to  the  possibilities  of  relationship  between 
functional  and  organic  disorders,  it  would  seem  wisest,  as  an 
introduction  to  what  I  have  to  say  regarding  the  constitutional 
abnormalities  in  dementia  praecox,  to  put  together  the  fundamental 
dififerences  which  seem  to  exist  between  the  plainly  organic  dis- 

^  Elaborated  from  a  paper  read  at  the  New  York  Psychiatrical  Society. 
November  4,  1908. 

Ill 


112  FACTORS    IN   DEMENTIA    PRECOX   GROUP 

orders  like  general  paralysis  on  the  one  hand,  and  the  dementia 
prarcox  group  on  the  other  hand. 

In  the  first  place,  the  dementia  in  the  plainly  organic  disorders 
is  different  from  that  of  dementia  praecox.  In  the  former  we 
find  that  the  dementia  represents  a  diffuse  disorder  of  activisation 
of  memories — and  hence  gives  rise  to  a  diffuse  defect  of  elabora- 
tion, retention,  memory,  orientation,  etc.  In  dementia  praecox  it 
shows  itself  essentially  in  the  sphere  of  interest  in  the  environ- 
ment, and  in  a  peculiar  distortion  of  the  train  of  thought.  In  the 
second  place,  in  the  organic  disorders  we  find  that  the  content^  of 
the  psychosis  is  of  secondary  importance,  while  in  dementia  praecox 
the  content  seems  to  stand  in  the  very  foreground  of  the  clinical 
picture ;  the  content  is,  moreover,  apt  to  be  peculiarly  limited,  so 
that  in  patients  who  are  accessible  to  an  analysis  we  find  the  exist- 
ence of  special  trends  which  account  for  the  entire  content.  This 
is  something  which  these  cases  of  dementia  praecox  have  in  com- 
mon with  disorders  such  as  hysteria,  certain  simple  paranoic  states 
and  some  psychoses  of  degenerates,  that  is,  conditions  in  which 
the  psychogenic  nature  of  the  symptoms  is  now  scarcely  ques- 
tioned by  anyone.  It  is  well  to  remember  in  this  connection  that 
the  above  mentioned  states,  to  which  we  shall  again  have  to  refer 
later,  are  not  always  easily  differentiated  from  dementia  praecox; 
probably  this  difficulty  exists  not  merely  owing  to  our  inadequate 
diagnostic  facilities,  but  also  owing  to  the  closer  relationship  which 
these  conditions  bear  to  the  disease  in  question. 

Finally,  we  find  that  dementia  praecox  presents  yet  another  side 
which  would  point  to  a  certain  kinship  with  these  psychogenic 
disorders.  I  mean  the  fact  that  the  relationship  between  the  per- 
sonality, the  special  mental  make-up  of  the  individual  and  the 
psychosis,  is  a  much  closer  one,  the  constitutional  factors  of  much 
more  determining  importance  in  the  development  than  in  the 
organic  disorders,  where  we  often  find  either  no  appreciable  pecu- 
liarity of  mental  make-up,  or  where,  at  any  rate,  we  have  no  rea- 
son to  think  that  the  essential  manifestations  of  the  psychosis 
grow,  as  it  were,  out  of  the  personality. 

^The  term  content  is  here  used  in  the  sense  in  which  Jung  has  used  it 
in  his  "  Inhalt  dti'  Psychose "  (Leipzig  u.  Wien,  Franz  Deuticke,  igo8). 
and  therefore  contrasted  to  the  formal  disorders  which  have  received 
more  attention. 


FACTORS   IN   DEMENTIA   PRECOX   GROUP  II3 

It  is  obvious,  therefore,  that  there  are  quite  a  number  of  impor- 
tant considerations  which  show  that  whatever  anatomical  changes 
may  be  found,  their  relationship  to  the  disorder  is  evidently  not 
so  simple  as  in  those  diseases  which  are  clearly  organic ;  and  it  is 
therefore  necessary  to  insist  that,  in  addition  to  a  study  of  anatom- 
ical and  chemical  alterations,  there  is  a  vast  field  of  inquiry  at 
least  as  important  and  more  accessible  for  the  elucidation  of  the 
nature  of  the  disorder,  namely,  the  study  of  the  personality  and 
the  study  of  the  development  and  the  content  of  the  psychosis. 

I  wish  to  dwell  in  this  communication  upon  the  study  of  the 
make-up  only,  and  more  particularly  on  the  type  most  frequently 
seen.  It  will  be  remembered  that  it  was  Adolf  Meyer  who,  since 
1903,  has  insisted  that  dementia  prsecox  is  a  disorder  which  may 
not  develop  in  anyone,  but  that  only  some  personalities  are  in 
danger,  and  that  in  the  development  inadequate  psycho-biological 
habits  play  an  important  part  ( i ) . 

If  we  succeed  in  obtaining  accurate  anamneses  from  which  we 
are  able  to  form  an  opinion  of  the  personality  as  it  existed  before 
the  psychosis,  or  before  the  incubation  period,  as  it  is  sometimes 
called,  a  certain  type  of  personality  recurs  with  striking  frequency, 
that  which  I  have  called  the  "  shut-in  personality"  (2)  the  signifi- 
cance of  which  I  wish  to  discuss  more  particularly.  We  may 
start  with  a  few  examples. 

One  patient,  a  married  woman  of  nineteen,  is  said  to  have  been  quick 
enough  to  learn,  and  to  have  studied  much ;  she  was  also  a  frequent 
church-goer,  especially  since  the  age  of  sixteen,  without,  however,  taking 
an  active  part  in  the  church  work.  Even  before  the  age  of  five  she  did 
not  get  on  with  other  children,  did  not  play  with  them,  but  was  inclined 
to  keep  to  herself.  When  people  came  to  the  house  she  left  the  room ; 
she  was  described  as  always  "  helpless  "  in  company.  She  was  not  liked  in 
school,  and  never  helped  others.  She  was  hard  to  influence — did  not  take 
advice.  She  was  over-systematic ;  wanted  things  which  belonged  to  her 
left  alone.  She  was  sensitive  and  cried  when  interfered  with,  and  was  apt 
not  to  get  over  the  upset  for  days.  She  saw  faults  in  others,  rather  than 
her  own  defects ;  thought  she  was  better  than  her  fellows,  but  did  not  assert 
herself.  She  never  confided  in  anyone.  She  married  when  eighteen,  and 
during  her  first  pregnancy  was  uncommonly  insistent  in  her  desire  to 
have  a  boy  who  should  not  have  red  hair,  and  when  it  was  a  girl  with 
red  hair  she  lost  interest,  and  the  psychosis  at  once  developed. 

The  second  patient  is  said,  especially  since  the  age  of  eight,  sub- 
sequent to  an  attack  of  measles,  to  have  grasped  her  studies  less  well  than 


114  FACTORS   IN   DEMENTIA   PRECOX  GROUP 

before,  was  always  self-conscious,  felt  awkward  in  company  and  was 
sensitive,  but  she  said  little  about  it,  and  in  general  talked  very  little.  The 
mother  says  that  the  patient  was  in  this  respect  much  like  her  father, 
who  was,  however,  a  successful,  active  man.  She  often  sat  brooding,  was 
uncommonly  systematic  and  "  finicky."  At  puberty  the  seclusiveness  be- 
came more  marked.  At  seventeen  she  went  to  a  fortune-teller,  who  told 
her  she  would  go  insane,  which  prediction  is  said  to  have  occupied  her 
mind  a  good  deal.  At  eighteen  she  fell  in  love,  but  her  love  was  not  recip- 
rocated. Then  she  began  to  grow  absent-minded  and  careless,  and  gradu- 
ally drifted  into  a  deterioration. 

Case  3  represents  a  somewhat  different  type,  yet  still  with  well-marked 
traits  pointing  in  the  same  direction.  The  patient,  a  woman  of  thirty-six, 
who  always,  even  as  a  child,  was  sensitive  and  stubborn.  She  often  left 
the  table  at  the  slightest  provocation,  was  hard  to  guide  and  influence.  It 
is  remembered  that  she  herself  would  say  that  she  was  as  immovable  as  a 
post.  She  was  married  at  twenty,  did  not  find  her  husband  congenial, 
had  a  tendency  to  romanticism,  never  adapted  herself  to  her  simple  life, 
made  demands  upon  her  husband  which  she  knew  he  could  not  meet. 
Her  circumstances  as  well  as  her  inclinations  isolated  her.  She  was 
moody.  Repeatedly  she  got  suspicions  of  her  husband,  she  fell  silently  in 
love  with  a  dentist,  had  fancies  about  him,  and,  for  several  years  before 
the  onset,  refused  to  have  any  intercourse  with  her  husband.  She  broke 
down  only  at  thirty-six,  and  deteriorated. 

These  cases  suffice  to  show  that  we  find,  in  dementia  prsecox, 
persons  who  do  not  have  a  natural  tendency  to  be  open,  and  to 
get  into  contact  with  the  environment,  who  are  reticent,  seclusive, 
who  cannot  adapt  themselves  to  situations,  who  are  hard  to 
influence,  often  sensitive  and  stubborn,  but  the  latter  more  in  a 
passive  than  in  an  active  way.  They  show  little  interest  in  what 
goes  on,  often  do  not  participate  in  the  pleasures,  cares  and 
pursuits  of  those  about  them;  although  often  sensitive  they  do 
not  let  others  know  what  their  conflicts  are ;  they  do  not  unbur- 
den their  minds,  are  shy,  and  have  a  tendency  to  live  in  a  world 
of  fancies.     This  is  the  shut-in  personality. 

As  I  have  said,  this  type  of  make-up  is  very  common  in  de- 
mentia prsecox.  In  a  study  of  my  older  material  from  the 
M'Lean  Hospital,  Waverly,  Mass.  (72  cases),  I  found  that  in 
35  per  cent,  of  the  cases  it  was  markedly  pronounced,  whereas 
in  16  per  cent,  it  was  indicated,  so  that  there  was  some  evidence 
of  it  in  51  per  cent.  When  we  consider  that  these  findings  refer 
to  a  time  when  we  did  not  especially  look  for  these  traits,  these 
figures    are    all    the    more    striking.     Other    abnormalities    of 


FACTORS   IN   DEMENTIA   PRECOX  GROUP  I  I  5 

make-up  were  noted  in  15  per  cent.;  the  make-up  was  not  de- 
scribed in  9  per  cent.,  and  in  23  per  cent,  the  claim  was  made 
in  the  anamnesis  that  the  patient's  tendencies  were  "  natural." 
In  my  more  recent  material  of  the  Woman's  department  at 
Bloomingdale  Hospital,  N.Y.,  from  which  I  excluded  the  cases 
in  which  the  facts  were  not  accessible — a  small  material,  to  be 
sure,  amounting  only  to  38  cases — I  found  a  typical  shut-in 
personality  in  49  per  cent,  of  the  cases,  indication  of  it  in  further 
19  per  cent.,  making  a  total  of  68  per  cent,  altogether.  24  per 
cent,  of  the  cases  are  described  as  showing  peculiarities  of  other 
types.  It  is  interesting  that  among  the  cases  who  unquestionably 
deteriorated,  the  typical  shut-in  personality  was  most  often  seen, 
occurring  in  66  per  cent.  On  the  other  hand,  in  the  cases  who 
did  not  show  definite  deterioration,  in  other  words,  who  either 
got  well  or,  while  presenting  chronic  symptoms  did  not  lose  their 
interest  in  the  environment  to  any  marked  degree  and  whose 
train  of  thought  did  not  get  confused — a  group  including  cases 
which  form  a  transition  to  the  simpler  paranoic  states — we  found 
either  indications  of  the  shut-in  personality  or,  still  more  fre- 
quently, other  abnormalities  of  make-up,  such  as  long-standing 
neurasthenoid  states,  shallowness  of  emotion,  lack  of  considera- 
tion for  the  environment,  or  abnormal  insistence  on  precision, 
a  tendency  to  day-dreaming,  evidence  of  a  poorly-balanced  sexual 
instinct;  as  in  one  case  who  for  years  had  drifted  into  strikingly 
fruitless  love-affairs,  another  who  showed  jealousy  of  the  hus- 
band for  years  before  the  onset  and  ever  since  marriage.  But 
I  do  not  propose  to  go  into  this  part  of  the  topic,  as  it  would 
lead  me  too  far,  and  should  form  the  theme  of  a  more  extended 
investigation.  Finally,  I  found  only  8  per  cent,  in  which  there 
seemed  to  be  a  normal  make-up. 

Zablocka  (3),  who  studied  the  dementia  praecox  material  of  the 
Ziirich  clinic  in  regard  to  prognosis,  found  that  the  shut-in  per- 
sonality is  seen  more  often  in  the  deteriorating  than  in  the  other 
cases.  In  this  connection  it  should  be  remembered  that  the 
group  of  dementia  praecox  in  Ziirich  is  very  large,  and  includes 
many  mild  cases  which  we  would  not  regard  as  dementia  praecox. 

Of  great  interest  is  an  excellent  study  which  Dr.  Kirby  (4) 
has  recently  reported  at  the  New  York  Academy  of  Medicine,  in 
which  he  took  up  about  100  cases  of  dementia  praecox  observed 


Il6  FACTORS   IN   DEMENTIA   PRECOX   GROUP 

at  the  Psychiatric  Institute,  and  found  in  over  50  per  cent,  a 
plainly  shut-in  personality,  and  only  in  a  small  percentage  an 
apparently  normal  make-up. 

These  figures  seem  to  me  to  tell  the  story  plainly  enough. 
That  all  cases  should  show  clear  indications  of  a  shut-in  person- 
ality is  not  to  be  expected.  That  as  many  as  68  per  cent,  pre- 
sented evidence  of  it  in  my  recent  material,  over  50  per  cent,  in 
that  of  Dr.  Kirby,  over  50  per  cent,  in  my  older  cases,  and  that 
comparatively  few  cases  show  a  normal  make-up — ^these  are  data 
which  cannot  be  neglected. 

The  shut-in  personality,  after  all,  shows  only  the  direction  in 
which  the  dangerous  traits  lie,  and  it  is  fair  to  assume  that  other 
abnormalities  which  we  cannot  as  yet  clearly  define  may  work 
in  the  same  direction.  The  lack  of  contact  with  reality  may  be 
only  partial,  whereas  the  general  response  is  fair ;  or  other  traits 
which  seem  to  interfere  with  satisfactory  contact,  or  which  foster 
day-dreaming  or  which  interfere  with  the  formation  of  objective 
interests,  may  be  of  importance.  Kirby  has  pointed  out  that  a 
certain  shallowness  of  interest  without  a  general  shutting-in  was 
not  rarely  seen  in  those  of  his  cases  which  did  not  show  the 
typical  make-up.  Finally,  we  must  not  forget  that  behind  a 
correct  appearance,  the  result  of  a  formal  training,  there  may  be 
much  that  is  not  apparent  in  ordinary  life,  but  which  at  any  time 
may  under  stress  come  to  the  surface.  The  fact  that  these  same 
traits  are  not  seen  in  manic-depressive  insanity  is  certainly  very 
interesting  as  a  control.  How  much  of  it  does  occur  in  normal 
persons  is  difficult  to  estimate. 

It  may  not  be  out  of  place  here  to  say  that  in  a  question  of 
the  importance  or  the  danger  of  certain  traits,  the  whole  bearing 
of  which  we  do  not  yet  know,  it  is  difficult  to  estimate  the  limits 
of  elasticity  until  sufficient  strain  has  been  exerted  to  test  it. 

We  cannot  help  feeling  that  to  a  certain  extent  these  char- 
acteristics must  in  themselves  represent  a  reaction  to  something 
more  fundamental,  but  evidently  a  reaction  along  a  special  bent 
of  the  personality,  and  one  which  owing  to  its  very  nature  has 
certain  cumulative  tendencies. 

Freud  has  shown  us  that  in  the  neuroses  we  are  dealing  pri- 
marily with  a  lack  of  adaptation  to  reality  in  the  sexual  sphere, 
with  an  inadequate  or  faulty  development  of  the  instinct  in  its 


FACTORS   IN   DEMENTIA   PRECOX  GROUP  11/ 

wider  meaning,  in  the  sense  that  owing  to  a  certain  fixation  and 
limitation  of  the  interest  in  that  sphere  in  childhood,  and  owing 
to  subsequent  repression,  the  later  free  application  and  adaptation 
is  interfered  with.  This  is  not  the  place  to  enter  into  a  discussion 
of  this  view  which  Freud  has  expressed  in  his  earlier  writings, 
and  again  very  clearly  in  his  recent  Worcester  lectures  (5), 
and  which  Jung  has  extensively  supported  by  his  own  studies. 
Important  for  us  in  this  discussion  is  the  fact  that  Jung  has  in- 
sisted that  a  similar  sort  of  abnormality  in  the  sphere  of  the 
sexual  instinct  exists  in  dementia  praecox.  While  I  have  person- 
ally not  analyzed  a  sufficient  material  with  the  view  of  verifying 
this  claim  from  direct  evidence,  I  am  nevertheless  inclined  to 
regard  this  as  very  probably  a  correct  one,  for  the  following 
reasons :  In  the  first  place,  we  should  mention  the  close  relation- 
ship which  exists  between  dementia  praecox  and  puberty.  Sec- 
ondly, the  fact  that  everyone  who  has  attempted  to  enter  into  the 
lives  and  struggles  of  these  patients  must  have  been  impressed 
with  the  frequency  with  which  sexual  conflicts  are  found  to  have 
played  an  important  role  in  the  development  of  the  disorder. 
Thirdly,  analysis  of  the  content  of  the  psychosis  shows  us  again 
and  again  the  existence  of  sexual  trends,  and  often  when  the 
sexuality  manifests  itself,  it  does  so  in  a  peculiarly  diffuse,  poorly 
adapted  manner,  such  as  in  the  falling  in  love  with  several  per- 
sons at  the  same  time,  and  the  like.  All  this  cannot  be  accidental. 
There  is,  therefore,  much  that  speaks  in  favor  of  the  claim  of 
a  fundamental  lack  of  sexual  adaptability ;  but,  according  to  those 
who  have  analysed  the  neuroses  of  various  kinds,  we  find  there 
similar  difficulties,  but  without  equally  serious  consequences. 

We  are  scarcely  prepared  to  say  what  is  fundamentally  the 
nature  of  the  lack  of  sexual  adaptability,  and  what  is  its  relation 
to  the  shut-in  personality.  However,  Abraham  (6),  who  has 
fully  recognized  the  importance  of  the  shut-in  personality,  has 
attempted  to  answer  this  question.  He  regards  the  lack  of  sexual 
adaptability  as  due  to  an  arrest  of  sexual  development,  a  per- 
manent retention  of  the  infantile  autoerotic  stage,  and  looks  upon 
the  shut-in  tendency  as  one  of  the  expressions  of  this  autoerotism. 
This  is  certainly  a  clever  hypothesis,  but  we  cannot  help  feeling 
that  the  question  is  more  complicated. 

But  even  without  knowing  what  is  the  origin  or  the  funda- 


Il8  FACTORS   IN  DEMENTIA   PRECOX   GROUP 

mental  meaning  of  the  constitution  we  have  described,  we  can 
see,  nevertheless,  reasons  why  such  a  constitution  should  repre- 
sent a  serious  menace  to  the  mental  balance  of  the  personality. 

The  inability  to  get  into  contact  with  the  environment  bears 
in  itself  many  dangers;  it  prevents  an  active  aggressive  shaping 
of  the  situation  which  is  so  impoi-tant  for  the  progress  of  the 
normal  individual  and  which  forestalls  further  conflicts ;  it  pre- 
vents the  corrective  influences  which  actual  experience  constantly 
furnishes,  and  which  is  gained  in  the  mingling  with  people,  the 
mutual  actions  and  reactions;  it  fosters  the  growth  of  unpro- 
ductive fancies.  Everyone  has  a  certain  inclination  to  day- 
dreaming, but,  aside  from  the  fact  that  it  plays  a  rather  subsid- 
iary role  in  the  normal  robust  person,  the  fancies  often  represent 
in  them  the  first  dim  outlines  of  future  plans,  and  therefore  are 
not  without  reference  to  reality,  and  receive  their  value  from  that 
side;  but  fancies  which  are  out  of  contact  with  reality  probably 
exert  in  themselves  a  certain  fascination  which  progressively 
limits  objective  interest.  Moreover,  these  very  tendencies  make 
the  individual  unfit  to  acquire  those  constructive  plans  and  hopes, 
not  necessarily  elaborated,  but  felt,  dimly  appreciated,  upon  which 
the  normal  person  lives,  and  which  give  to  him  the  very  essence 
of  his  existence.  There  is  an  absence  of  that  progressive,  pros- 
pective satisfaction  which  cannot  be  too  much  insisted  upon  as 
necessary  for  the  retention  of  mental  health.  The  active  contact 
with  the  world  makes,  of  course,  more  demands  upon  the  individ- 
ual than  a  life  in  pure  fancies,  towards  which  the  path  of  least 
resistance  evidently  leads  in  these  patients.  We  see,  therefore, 
that  the  traits  upon  which  we  would  lay  most  stress  in  the  shut-in 
personality,  the  lack  of  contact  with  the  environment,  the  satis- 
faction with  fancies  instead  of  objective  interests,  the  lack  of 
constructive  aims  and  aggressiveness,  must  have  dangers  in  them 
which  it  would  be  difficult  to  exclude  as  dynamic  factors  in  the 
development  of  these  disorders,  and  we  must  agree  with  Adolf 
Meyer  when  he  has  again  and  again  insisted  upon  the  importance 
of  faulty  psycho-biological  habits  in  connection  with  dementia 
prsecox. 

It  will  now  be  of  interest  to  briefly  review  some  constitutional 
abnormalities  in  groups  of  cases  which  present  a  certain  kinship 
to  dementia  praecox, — I  mean  in  hysteria,  certain  paranoic  states. 


FACTORS   IN   DEMENTIA   PRvECOX  GROUP 


119 


and  the  psychoses  of  degenerates  recently  reported  by  Birnbaum ; 
cases  therefore  in  which,  and  this  is  the  point  I  wish  to  emphasize 
more  particularly,  deterioration  does  not  occur.  In  hysteria,  in 
which  disorder  we  have,  as  was  above  stated,  according  to  Freud, 
also  a  certain  lack  of  sexual  adaptability,  we  find  a  very  different 
sort  of  personality.  Here  there  is  no  lack  of  aggressiveness,  nor 
lack  of  contact  with  the  environment,  nor  an  absence  of  objective 
interest;  on  the  contrary,  we  find  a  constant  reference  to  the 
persons  about,  a  desire  to  be  in  the  centre  of  observation;  hys- 
terical patients  force  us  with  all  means  at  their  disposal  to  occupy 
ourselves  with  them. 

In  paranoic  states,  too,  the  contact  with  the  environment  is 
plain;  these  persons  are  sensitive,  and  markedly  concerned  about 
the  rest  of  the  world,  they  expect  something  from  it,  and  with  all 
their  suspiciousness  they  are  not  without  a  certain  open  attitude 
in  the  sense  of  aggressiveness  and  a  desire  to  seek  contact.  An- 
other equally  important  difference  between  the  paranoic  state  and 
the  condition  of  dementia  praecox  is  to  be  found  in  the  fact  that 
sometimes  the  external  situation  is  a  much  more  potent  factor  in 
the  causal  constellation  of  the  former,  as  is  seen  in  the  paranoia 
quaerulans,  and  other  paranoic  states,  such  as  those  reported  by 
Gierlich  (7)  and  Friedmann  (8),  or  those  more  recently  by 
Riidin  (9). 

We  may  finally  consider  that  interesting  group  of  cases  which 
lately  has  been  taken  up  by  Birnbaum  (10),  the  first  German  who 
fully  recognized  the  claims  of  the  French  school  regarding  the 
delire  des  degeneres.  It  is  interesting  that  these  are  psychoses 
which  often  resemble  in  their  mechanisms  those  of  dementia 
praecox,  so  much  so  that  Bleuler  (11),  one  of  the  investigators 
best  acquainted  with  the  psychology  of  dementia  praecox,  has  met 
Birnbaum  with  the  statement  that  the  latter  had  not  succeeded 
in  giving  a  differentiation  beween  his  cases  and  dementia  praecox. 
To  this  Birnbaum  has  given,  what  I  consider  a  satisfactory  reply :' 
there  is  much  that  separates  the  two  groups  if  one  considers  well- 
marked  cases  of  either  group,  but  it  does  not  seem  unlikely  that 
transitions  occur,  although  plainer  transitions  exist  between  these 
psychoses  of  degenerates  and  hysteria. 

•In  Centralblatt  f.  Nervenheilkunde  und  Psychiatric,  1909,  p.  429, 
although  I  cannot  by  any  means  agree  with  his  entire  position. 


I20  FACTORS   IN   DEMENTIA   PRECOX  GROUP 

In  the  group  which  Birnbaum  has  described  we  find  individ- 
uals with  criminal  tendencies  who,  under  the  influence  of  punish- 
ment, imprisonment,  frustrated  escapes,  denials  of  pardon, 
announcement  of  a  new  indictment,  etc.,  developed  psychoses  with 
delusions,  hallucinations,  and  other  symptoms  in  which  the  ele- 
ment of  wish-fulfilment  takes  a  very  prominent  and  easily  recog- 
nized place.  The  disorder,  then,  depends  strikingly  upon  external 
difficulties  and  often  disappears  with  the  removal  of  the  latter. 
As  to  the  make-up,  these  personalities,  besides  presenting  criminal 
tendencies,  are  unstable,  without  much  determination  or  depth 
of  feeling,  though  with  a  tendency  to  outbursts  of  feelings ;  they 
are  fickle,  frivolous,  unable  to  stick  to  any  occupation,  suggestible, 
imaginative,  eccentric,  given  to  fantastic  schemes,  untruthful. 
These  patients,  then,  do  not  show  a  lack  of  contact  with  the  en- 
vironment, they  even  present  a  certain  ill-directed  aggressiveness. 
They  are,  therefore,  in  many  ways  different  from  individuals 
with  a  shut-in  personality.  In  another  point  they  differ,  namely, 
in  the  fact  that  their  conflicts  are  on  the  surface;  they  are  in  a 
scrape,  to  put  it  tersely,  and  the  content  of  the  psychosis  is  a 
reaction  to  the  scrape.  Hence  the  make-up  as  well  as  the  situa- 
tion differs  from  that  of  dementia  prsecox,  although  the  mechan- 
isms are,  as  we  said,  often  not  unlike  those  seen  in  dementia 
prsecox. 

This  putting  side  by  side  of  the  constitutional  traits  of  hysteria, 
paranoic  states,  and  certain  psychoses  of  degenerates  on  the  one, 
and  dementia  praecox  on  the  other  hand ;  this  contrast  of  groups 
of  cases  which  show  no  tendency  to  deterioration  with  a  group 
of  cases  in  which  deterioration  is  an  important  feature,  seemed 
to  me  to  be  of  value,  because  it  can  hardly  be  regarded  as  acci- 
dental that  those  who  deteriorate  show  original  defects  in  the 
direction  which  we  have  indicated,  while  those  who  do  not  dete- 
riorate are  singularly  free  from  those  very  traits ;  nor  is  the  prom- 
inence of  external  factors  in  paranoic  states  and  in  the  degene- 
rates, in  contradistinction  to  the  essentially  internal  conflicts  in 
dementia  praecox,  likely  to  be  accidental  and  without  bearing  on 
the  question  of  the  outcome. 

Having  then  shown  the  prevalence  of  the  shut-in  personality 
in  dementia  prsecox,  and  its  absence  in  the  non-deteriorating  cases, 


FACTORS   IN   DEMENTIA   PRECOX   GROUP  121 

it  is  left  for  us  to  point  out  certain  relationships  between  the  traits 
we  have  brought  out  and  the  symptom  pictures  early  and  late. 

In  the  first  place,  it  is  well  known  that  the  incubation  period, 
if  we  may  be  allowed  the  term — a  period  that  often  lasts  several 
years — is  almost  always  marked  by  an  accentuation  of  the 
shut-in  traits,  the  patient  gets  further  away  from  the  environ- 
ment. Secondly,  we  can  scarcely  help  seeing  the  close  relation- 
ship which  exists  between  the  constitutional  traits  and  the  nega- 
tivism, and  last,  but  not  least,  between  these  traits  and  the  final 
deterioration.  What  is,  after  all,  the  deterioration  in  dementia 
praecox  if  not  the  expression  of  the  constitutional  tendencies  in 
their  extreme  form,  a  shutting-out  of  the  outside  world,  a  de- 
terioration of  interests  in  the  environment,  a  living  in  a  world 
apart  ? 

All  these  considerations  will,  I  hope,  make  clear  that  the  con- 
stitutional abnormalities  which  we  have  described,  and  which  in 
their  most  marked  form  probably  represent  the  direction  in  which 
the  important  traits  lie,  must  be  the  expression  of  dynamic  forces 
of  great  importance. 

References 

1.  Adolf  Meyer.  An  Attempt  at  Analysis  of  the  Neurotic  Constitution, 
Amer.  Journ.  of  Psychol.,  Vol.  XIV,  pp.  90-103,  1903.  Also  Fundamental 
Conceptions  of  Dementia  praecox,  British  Medical  Journal,  Sept.  20,  1906; 
The  Dynamic  Interpretation  of  Dementia  Praecox,  Amer.  Journ.  of 
Psychol.,  July  1910,  Vol.  XXI,  pp.  385-403. 

2.  Hoch.  A  Study  of  the  Mental  Make-up  in  the  Functional  Psychoses. 
Abstract  of  paper  read  before  the  New  York  Psychiatrical  Society,  Nov.  4, 
1908.  Journ.  of  Nervous  and  Mental  Disease,  April,  1909,  Vol.  XXXVI, 
p.  230. 

3.  Zablocka.  Zur  Prognosestellung  der  Dementia  Praecox,  Allgemeine 
Zeitschr.  f.  Psychiatric,  Vol.  LXXV,  pp.  318-339. 

4.  Not  published. 

5.  Freud.  Drei  Abhandlungen  zur  Sexualtheorie,  and  Uber  Psycho- 
analyse. Franz  Deuticke,  Wien,  1910.  This  Monograph  Series.  No.  7 
in  Translation. 

6.  Abraham.  Die  psychosexuellen  Differenzen  der  Hysteric  und  der 
Dementia  Praecox,  Centralblatt  f.  Nervenheilkunde  und  Psychiatric,  July, 
1908. 

7.  Gierlich.  t)ber  periodische  Paranoia  und  die  Entstehung  der  para- 
noiden  Wahnideen,  Arch.  f.  Psychiatric,  Vol.  I,  pp.  19-40,  1905. 

8.  Fricdmann.  Beitrage  zur  Lehre  von  der  Paranoia,  Monatsschr.  f. 
Psychiatric  und  Neurologic,  Vol.  XVII,  pp.  468,  532. 

These  two  translated  in  this  Monograph  Series  No.  2. 


122  FACTORS   IN  DEMENTIA   PRECOX  GROUP 

9.  Riidin.  t)ber  die  klinischen  Formen  der  Seelenstorungen  bei  zu 
lebenslanglicher  Zuchthausstrafe  Verurteilten.  Miinchen,  1909.  Review 
Centralblatt  fiir  Nervenheilkunde  und  Psychiatric,  1909,  p.  292. 

10.  Birnbaum.  Psychosen  mit  Wahnbildung  und  wahnhafte  Einbild- 
ungen  bei  Degenerativen.     Carl  Marhold,  Halle,  1908. 

11.  Bleuler.  Wahnhafte  Einbildungen  der  Degenerierten,  Centralblatt 
f.  Psychiatrie  u.  Neurologic,  1909,  pp.  77-80. 


COMPARATIVE  PSYCHOLOGICAL  STUDIES  OF  THE 

MENTAL  CAPACITY  IN   CASES  OF  DEMENTIA 

PRECOX  AND   ALCOHOLIC   INSANITY^ 

By  Henry  A.   Cotton,  M.D., 

MEDICAL   DIRECTOR,    NEW    JERSEY   STATE   HOSPITAL   AT  TRENTON 

(From  the  Psychological  Laboratory  of  the  Royal   Psychiatric  Clinic  at 
Munich.     Professor  Kraepelin,  Director) 

Scope  and  Object  of  the  Investigation 

The  work  of  the  investigators  in  the  field  of  experimental 
psychology  in  recent  years  has  shown  remarkable  progress,  so 
that  new  light  has  been  shed  upon  a  great  many  obscure  and  com- 
plicated problems  connected  with  our  mental  life. 

Mere  speculation  as  to  the  mechanism  of  fundamental  psychical 
processes  has  given  place  to  some  extent  to  more  accurate  knowl- 
edge of  these  problems,  so  that  today  many  obscure  and  compli- 
cated reactions  can  be  graphically  demonstrated  and  these  same 
processes  spoken  of  in  terms  of  mechanical  values  and  equivalents. 
To  reduce  these  complicated  processes  to  figures  and  curves  has 
been  a  stupendous  task  in  the  field  of  normal  psychology,  and 
much  remains  to  be  accomplished  before  we  can  have  an  accurate 
idea  of  all  psychical  phenomena. 

That  the  experiments  with  normal  individuals  have  not  been 
entirely  successful  is  due  partly  to  a  lack  of  methods,  and  partly 
to  defects  in  some  of  the  methods  devised.  If  this  be  true  of  the 
field  of  normal  psychology,  then  we  cannot  wonder  that  investi- 
gators in  the  field  of  abnormal  psychology  have  experienced  great 
difficulties  in  representing  by  graphic  methods  the  complicated 
abnormal  psychical  processes  in  the  insane. 

The  effects  of  drugs  and  poisons  upon  the  psychical  processes 
have  been  graphically  shown  by  Kraepelin  and  his  pupils,  and 
their  work  has  been  of  immense  importance  in  paving  the  way 

^Read  before  the  New  York  Psychiatrical  Society. 

123 


124  MENTAL    CAPACITY   IN    DEMENTIA    PRECOX 

for  a  better  understanding  of  abnormal  psychological  phenomena. 
But  experiments  with  normal  individuals  do  not  present  such 
obstacles  as  we  find  when  we  attempt  to  analyze  abnormal  psy- 
chical processes  of  the  insane  by  similar  methods.  The  normal 
processes  with  and  without  the  eflfect  of  the  poisons  can  be  care- 
fully analyzed  and  compared  in  the  same  individual,  whereas,  in 
the  experiments  in  abnormal  psychology,  we  must  compare  sim- 
ilar experiments  upon  normal  individuals  with  the  results  in 
abnormal  individuals  or  the  insane. 

Methods  that  are  readily  adapted  to  the  normal  individual 
become  useless  when  applied  to  investigations  of  abnormal  mental 
conditions  as  found  in  the  insane.  Either  the  patients  absolutely 
refuse  to  perform  the  experiments,  or  only  partially  fulfill  the 
conditions,  and  the  figures  and  results  of  such  experiments  are 
not  comparable  with  similar  experiments  with  the  normal.  And 
such  figures  seldom  give  an  accurate  and  clear  picture  of  the 
pathological  mental  condition. 

We  have  studied  the  various  clinical  symptoms  of  the  insane, 
and  we  know  that  certain  symptoms  refer  to  disturbances  of  cer- 
tain psychical  fields.  The  problem  of  experimental  psychology 
is  to  measure  these  abnormal  reactions  and  compare  the  results 
of  such  measurements  with  those  obtained  in  normal  psychical 
processes. 

For  many  years  Kraepelin  has  searched  for  simple  methods 
which  were  suitable  for  abnormal  as  well  as  normal  persons,  and 
he  and  his  pupils  have  been  successful  in  finding  methods  that 
on  the  one  hand  were  suitable  for  studying  the  psychical  processes 
of  normal  persons,  while  on  the  other  hand,  they  were  adaptable 
to  abnormal  psychical  processes  as  well. 

His  method  of  continuous  addition  of  single  numbers  was  first 
used  in  experiments  with  normal  individuals,  and  occupied  two 
hours  a  day  continuously  for  its  completion.  By  this  simple 
method  he  succeeded  in  graphically  representing  some  very  im- 
portant psychical  processes,  and  also  the  relation  of  various 
processes  to  each  other,  i.  e.,  fatigue — the  effect  of  the  rest  or 
pause  during  addition,  in  which  recuperation  takes  place;  the 
effect  of  stimulation;  the  impulse  and  intensity  of  the  will,  and 
variations  in  the  will ;  and  the  increase  of  actual  work  done 
through  practice  and  familiarity  with  the  work.     Kraepelin  has 


MENTAL    CAPACITY   IN    DEMENTIA    PRECOX  12$ 

shown  this  in  his  monograph  on  the  "  Arbeitscurve,"^  and  in  one 
chart  all  these  various  processes  are  plotted,  and  can  be  graphically 
compared.  Kraepelin  admits  that  it  took  ten  years  of  experi- 
menting with  normal  individuals  before  he  could  interpret  all 
the  facts  shown  by  the  "  Arbeitscurve."  Gradually  Kraepelin 
shortened  the  time  from  two  hours  to  one  hour,  then  half  an 
hour,  until  finally  the  experiment  was  reduced  to  ten  minutes. 
It  was  soon  apparent  that  two  hours  continuous  addition  was 
very  fatiguing  to  a  normal  individual  and  wholly  unsuited  to 
abnormal  ones. 

Through  a  series  of  experiments  extending  over  these  ten  years 
it  was  found  that  the  length  of  time  in  the  various  experiments 
had  little  to  do  with  the  relation  of  the  various  phenomena;  that 
certain  laws  were  uniform,  whether  the  experiment  was  for  two 
hours  or  ten  minutes,  and  that  the  relation  of  these  phenomena 
were  shown  to  be  constant. 

The  method  used  in  investigations  by  the  author  of  this  paper 
is  practically  the  original  method  reduced  to  ten  minutes  work 
and  simplified.  And  in  spite  of  the  simplicity  and  crudeness  of 
the  method,  it  has  been  used  with  success  to  show  at  least  some 
of  the  abnormal  psychical  processes  of  the  insane. 

The  object  of  this  work  was  to  investigate  two  forms  of  psy- 
choses by  this  method,  i.  e.,  dementia  praecox  and  alcoholic  psy- 
choses, and  to  compare  the  results  obtained,  with  the  results  of  the 
experiments  on  normal  individuals  of  the  same  station  in  life  and 
grade  of  intelligence.  The  method  is  simply  a  continuous  addition 
of  single  numbers.  These  numbers  are  placed  in  long  columns, 
and  the  task  of  the  patient  is  to  add  consecutive  numbers  together 
and  place  the  result  opposite  these  numbers.  This  continues  for 
ten  minutes,  and  at  the  end  of  each  minute,  by  a  signal,  the 
patient  makes  a  line  to  indicate  the  same.  The  experiment  lasts 
ten  days.  On  alternate  days  a  five  minutes'  pause  or  rest  is  given, 
and  on  other  days  the  patient  adds  for  ten  minutes  without  any 
pause  or  rest.  Then  the  number  of  additions  during  each  minute 
is  taken  as  units  of  the  curve.  Experience  has  shown  that  the 
amount  of  time  lost  in  writing  the  result  is  very  small,  and 
extends  uniformly  over  the  entire  experiment,  and  need  not  be 

'  Die  Arbeitscurve,  Emil  Kraepelin,  Leipzig,  1902. 


126  MENTAL   CAPACITY   IN   DEMENTIA   PRECOX 

taken  into  account,  also,  that  mistakes  made  need  not  be  con- 
sidered, as  the  task  is  so  simple  that  any  one  who  has  a  rudi- 
mentary education  in  arithmetic  can  undertake  the  experiment. 

This  investigation  was  begun  in  the  Psychological  Laboratory 
of  the  Royal  Psychiatric  Clinic  in  Munich  in  the  spring  of  1906. 
The  patients  for  investigation  were  partly  from  the  Psychiatric 
Clinic  in  Munich,  and  partly  from  the  District  Insane  Hospital  at 
Egelfing,  in  the  vicinity  of  Munich.  The  experiment  with  the 
patients  is  a  comparatively  simple  matter,  but  calculating  the 
results  and  interpreting  the  same  is  extremely  difficult,  and  to 
Professor  Kraepelin  should  be  given  the  credit  for  a  large  share 
of  the  work,  for  without  his  assistance  in  interpreting  the  results 
the  experiment  would  have  been  worthless. 

We  have  investigated  altogether  fourteen  cases  of  alcoholic 
psychoses,  among  which  were  several  cases  of  delirium  tremens, 
alcoholic  hallucinosis,  and  chronic  alcoholic  insanity.  Also  twelve 
patients  with  dementia  praecox  who  were  in  the  first  stage  of  the 
disease,  mostly  the  catatonic  form.  The  figures  for  the  normal 
were  taken  from  the  work  of  Drs.  Plaut  and  Rehm  of  the  Psy- 
chiatric Clinic  in  Munich,  who  investigated  these  normal  cases 
in  conjunction  with  similar  work  with  manic  depressive  insanity 
and  psychasthenia. 

I  am  indebted  to  these  men  for  furnishing  me  with  figures  of 
normal  people,  and  for  their  assistance  in  preparing  this  work. 
I  wish  also  to  express  my  thanks  for  the  courtesy  of  the  assist- 
ants in  the  Clinic  of  Munich,  as  well  as  the  assistants  in  the  Dis- 
trict Insane  Hospital  at  Egelfing,  who  rendered  much  aid  in 
providing  suitable  patients  for  these  studies. 

The  Method  in  Detail 

As  we  have  mentioned  before,  the  method  consists  in  adding 
single  figures  together  and  placing  the  sum  opposite  the  printed 
numbers.  Thus,  a  page  of  printed  figures  is  before  the  patient, 
arranged  in  long  columns,  about  50  figures  to  a  column. 

These  experiments  are  performed  every  day  for  10  days.  On 
alternate  days  a  rest  of  five  minutes  is  allowed,  so  that  the  rest 
is  indicated  by  a  dotted  line  between  the  fifth  and  sixth  minute 
(see  Fig.  i). 


MENTAL    CAPACITY    IN   DEMENTIA   PRECOX 


127 


Thus 

, — 

8 

9 

17 

3 

12 

4 

7 

6 

10 

2 

8 

S 

7 

the  left  hand  figures  being  the  printed  figures,  and  the 
right  hand  figures  the  additions  of  consecutive  numbers. 
A  stop  watch  is  held  by  the  investigator,  and  at  the 
end  of  every  minute  the  patient  is  told  to  "mark," 
which  he  does,  and  goes  on  adding  until  the  10  minutes 
are  finished. 


The  curves  shown  in  Fig.  i,  are  made  up  as  follows:  The 
abscissa  represent  the  minutes  of  work  from  i  to  10,  and  the 
ordinate  represents  the  total  number  of  additions  performed  in 
each  minute.  The  curve  on  the  left  "without  pause,"  is  made 
from  the  work  on  alternate  days,  first,  third,  fifth,  etc.,  days,  and 
the  curve  on  the  right  "  with  pause,"  is  made  up  from  the  work 
on  the  second,  fourth,  sixth,  etc.,  days.  These  curves  represent 
the  average  of  each  five  days'  work.  To  illustrate,  one  example 
of  the  work  done  on  normal  persons  by  Wilhelm  Specht.  Below 
are  given  the  numbers  for  each  minute  in  the  ten  days'  inves- 
tigation. 


I 

. 

63 

54 

56 

52 

58 

56 

53 

52 

54 

52 

284 

266 

3 

. 

75 

66 

69 

67 

64 

68 

68 

66 

68 

62 

344 

329 

5- 


7- 


73 

69 

75 

71 

66 

70 

69 

67 

70 

70 

68 

72 

73 

68 

73 

356 

338 

360 

73 
71 
72 

74 
70 


360 


9 

. 

78 

75 

73 

71 

75 

66 

73 

66 

71 

65 

370 

343 

2 

48 

61 

44 

55 

43 

51 

44 

47 

44 

50 

223 

264 

i 

\ 

72 

69 

64 

66 

57 

66 

63 

64 

59 

64 

315 

329 

6 

73 

76 

67 

72 

70 

70 

67 

69 

68 

69 

345 

356 

8 


77 

80 

74 

72 

74 

67 

70 

70 

70 

70 

365 

359 

10 

74 

76 

74 

75 

75 

74 

73 

72 

72 

74 

368 

371 

In  the  above  table  the  vertical  figures  represent  the  number  of 
additions  in  minutes,  the  first  five  minutes  on  the  left  of  the 
vertical  line,  and  the  second  five  minutes  on  the  right,  and  the 
successive  days,  as  explained  above.  The  average  of  these  daily 
figures  is  shown  in  the  two  curves — in  Fig,  i  we  see  in  curve  h 
(with  pause)  that  there  is  a  decided  downward  course  of  the 
curve,  showing  a  drop  from  42.5  to  38.7  at  the  end  of  the  fifth 
minute.    The  cause  of  this  sinking  of  the  curve  is  due  principally 


128 


MENTAL   CAPACITY   IN    DEMENTIA   PRECOX 


to  fatigue  (mental)  as  the  mental  work  progresses.  But  there  is 
another  factor  to  be  considered,  and  that  is  practice.  For  prac- 
tice without  fatigue  would  show  an  increase  in  the  amount  of 
work  done,  and  the  curve  would  rise  instead  of  falling.  But  the 
fatigue  overbalances  the  practice  and  consequently  the  curve  sinks. 
After  a  five  minutes  pause,  it  will  be  noticed  that  the  work 


^ro 

¥10 

A 

430 

\ 

/\ 

«vo 

\ 

\                 *      \ 

<^/o 

^*-*^/^^v 

\               '         \ 

tfO^ 

v^ 

v.          1           \y^ 

S9c 

'V 

^*"~^ 

iro 

•                             • 

/  I  s  V  r  c   7  i  f  ^c  f  1,  )  V  r  c  ?  i  9  ^* 

a  b 

Fig.  I. 

done  in  the  sixth  minute  is  not  only  much  greater  in  amount  than 
at  the  fifth  minute  (directly  before  the  pause),  but  is  also  larger 
than  the  amount  done  at  the  beginning  of  the  experiment,  and 
consequently  we  find  the  curve  beginning  almost  at  44  instead  of 
42  the  first  minute. 

This  increase  in  the  amount  of  work  done  the  sixth  minute  is 
explained  by  two  facts  which  have  taken  place  during  the  five 
minutes'  rest  or  pause.  In  the  first  place  the  fatigue  has  been 
overcome  by  recuperation,  and  the  person  starts  out  freshened 
and  ready  to  work.  At  the  same  time  the  effect  of  the  practice 
of  the  first  five  minutes  has  some  value  in  the  amount  of  work 
done,  being  more  than  in  the  first  minute.  It  is  true  that  during 
the  pause  or  rest,  the  practice  has  to  a  small  degree  lost  its 
effect,  but  the  disappearance  of  fatigue  also  must  be  considered 
in  explaining  the  larger  value  of  the  work  in  the  sixth  minute. 
Especially  is  this  seen  in  comparing  the  work  of  the  sixth  minute 
in  curve  a.  Here  the  value  is  41  against  44  for  the  same  minute 
after  a  pause  of  five  minutes.  The  work  of  the  entire  five  min- 
utes after  the  rest  is  much  greater  than  the  work  of  the  first  five 
minutes.  Hence,  we  must  ascribe  the  increase  largely  to  the 
effect  of  recuperation  during  the  rest,  and  the  loss  of  fatigue. 


MENTAL    CAPACITY    IN   DEMENTIA   PRECOX  1 29 

From  Table  I  we  get  the  following  values :  The  numbers  on  the 
left  side  of  the  line  are  the  values  of  the  fifth  minute  before  the 
pause  for  five  days.  On  the  right  side  of  the  line  are  the  values 
for  the  sixth  minute  following  the  pause  for  five  days.  The  sum 
of  these  separate  columns  gives  the  total  amount  of  work  done 
in  the  fifth  and  sixth  minute,  with  an  intervening  pause. 


44 

61 

59 

69 

68 

1<> 

70 

80 

72 

76 

313 

362 

1 1.5   per   cent,   increase   after   the   rest. 

Here  is  shown  distinctly  the  effect  of  the  pause  or  rest  in  the 
II. 5  per  cent,  increase  in  work  done  in  the  sixth  minute  over 
that  done  in  the  fifth  minute  before  the  pause.     When  we  com- 
pare the  work  done  in  the  fifth  and  sixth  minutes  on  the  days 
with  the  pause  with  the  same  minutes  on  the  days  without  the 
pause,  we  see  in  curve  a  that  the  fifth  and  sixth  minutes  are 
practically  the  same,  that  no  increase  can  be  noticed  as  compared 
with  curve  h.    For  the  fatigue  has  been  compensated  in  the  latter, 
but  not  in  the  former  instance.     The  curve  shows  in  general  a 
descending  tendency  due,  as  we  stated  above,  to  the  overbalancing 
of  the  fatigue  over  the  practice,  but  the  fifth  and  sixth  minutes 
are  at  the  same  level.     The  slight  rise  of  the  curve  at  the  fifth 
minute  is  not  due  to  a  balance  between  the  fatigue  and  practice, 
but  to  the  effect  of  the  tension,  or  straining  of  the  will,  which 
overcomes  the  fatigue.    And  the  straining  of  the  will  frequently 
shows  itself  in  the  curves  and  is  considered  an  impulse  of  the 
will  to  overcome  the  fatigue.     This  impulse  is  effective  in  keep- 
ing the  amount  done  in  the  fifth  and  sixth  minute  at  the  same 
level.     Without  this  straining  of  the  will  in  the  course  of  the 
work,  both  values  of  the  fifth  and  sixth  minutes  would  be  much 
smaller  and  the  curve  would  descend  at  this  point  as  a  result  of 
fatigue.     So  that  11.5  per  cent,  increase  after  the  pause  stands 
for  the  direct  effect  of  the  pause,  when  taken  with  the  percentage 
of  increase  on  the  days  without  the  pause,  thus: 

1 1.5  per  cent,  increase  after  pause. 
0.0  per  cent,  increase  without  pause. 

ii.S  per  cent,  increase  after  pause,  or  direct  effect  of  pause. 
10 


130  MENTAL   CAPACITY   IN   DEMENTIA   PRECOX 

We  must  also  consider  the  total  amount  of  work  done  before 
the  pause  and  after  the  pause  or  the  total  work  of  the  first  five 
minutes  must  be  compared  with  the  total  work  of  the  five  min- 
utes after  the  pause,  and  also  compare  these  percentages  with 
those  obtained  in  the  same  manner  by  comparing  the  same  values 
of  the  days  without  a  pause. 

From  the  table  we  get  the  following  figures,  the  left  hand 
column  representing  the  total  work  of  the  first  five  minutes  for 
five  days,  and  on  the  right  side,  the  total  work  of  the  last  five 
minutes  after  the  pause. 


223 

264 

315 

329 

345 

356 

36s 

359 

368 

371 

1,616    1,679  =  3-3  per  cent,  increase  of  total  work  after  the  pause. 

This  increase  after  the  pause  is  explained  by  the  effect  of  the 
practice,  a  portion  of  which  remains  even  during  the  rest,  and 
therefore  more  work  is  accomplished  in  the  last  five  minutes, 
although  the  fatigue  also  plays  a  part  as  shown  by  the  descend- 
ing curve.  When  we  assume  that  during  the  pause  the  fatigue 
has  been  entirely  recuperated  by  the  rest,  then  the  increase  in 
work  after  the  pause  represents  the  practice  coefficient  of  the 
individual. 

Under  what  conditions,  and  in  what  manner  the  fatigue  is 
compensated  during  the  pause,  at  present  we  are  unable  to  state. 

Through  the  increase  of  the  work  after  the  pause,  although 
a  certain  residual  of  fatigue  is  present,  we  must  conclude  that 
the  practice  has  overcome  to  some  extent  the  fatigue.  The 
residual  can  be  great,  and  at  the  same  time  hidden  by  the  effect 
of  practice  when  the  latter  is  sufficiently  great.  And  we  can  also 
conclude  that  possibly  during  the  rest  or  pause,  that  the  fatigue  is 
entirely  compensated,  and  no  residual  remains,  and  that  the  effect 
of  practice  is  very  small. 

To  come  to  a  definite  conclusion  in  regard  to  this  question,  we 
must  first  compare  the  work  equivalents  of  the  days  when  no  rest 
was  taken,  and  where  consequently  the  effect  of  the  rest  does  not 
come  into  play.     From  the  table  we  again  take  the  following 


MENTAL   CAPACITY   IN   DEMENTIA    PRECOX  I3I 

figures.  The  figures  on  the  left  represent  the  total  work  of  the 
first  five  minutes  for  five  days,  and  on  the  right  of  the  column^ 
the  total  work  for  the  last  five  minutes  for  five  days. 


284 

366 

344 

329 

356 

338 

360 

300 

370 

343 

1,714 

1,636  =  4.1  per  cent,  decrease  in  last  five  minutes  over  first  five 

minutes. 

In  other  words,  without  the  good  effect  of  the  rest,  the  fatigue 
shows  itself,  and  the  work  fell  off  4.1  per  cent.  But  from  this 
coefficient  alone  we  cannot  compute  the  effect  of  fatigue.  In 
the  second  five  minutes  work  the  fatigue  overcomes  everything 
else,  but  we  cannot  tell  to  what  extent  the  total  amount  of  work 
has  been  influenced  by  the  simultaneous  opposing  effect  of  the 
practice. 

It  is  possible  that  the  decrease  of  the  work  in  the  second  five 
minutes  might  be  much  less,  if  the  individual  was  capable  of 
improving  by  practice.  We  get  an  idea  of  the  importance  of  the 
fatigue  when  we  compare  the  differences  in  the  total  amount  of 
work  done  after  the  pause  and  without  the  pause. 

That  the  work  of  the  second  five  minutes  on  the  days  without 
and  with  a  pause  or  rest,  approach  each  other  as  regards  the 
effect  of  practice,  can  be  shown.  However,  where  recuperation  of 
the  fatigue  during  the  pause  has  taken  place,  the  comparison  of 
days  without  any  rest  (where  the  second  five  minutes  is  under  the 
influence  of  the  fatigue)  and  the  days  with  rest,  the  difference 
in  the  two  series  will  give  us  the  value  of  the  fatigue.  This  dif- 
ference is  shown  below. 

3.3  per  cent,  increase  in  total  work  after  pause. 
4.1  per  cent,  increase  in  total  work  last  five  minutes, 

7.4  per  cent,  coefficient  of  fatigue. 

For  computing  the  individual  fatigue  we  make  use  of  two 
groups  of  figures  obtained  by  this  method  from  the  same  indi- 
vidual. On  one  hand  the  relation  of  work  values  of  the  fifth  and 
sixth  minutes,  and  on  the  other  hand,  the  difference  in  the  total 


132  MENTAL   CAPACITY   IN   DEMENTIA   PRECOX 

amount  of  work  done  in  the  first  and  second  five  minutes  on  the 
days  with  and  without  pause.  We  will  see  later,  when  discussing 
fatigue  in  our  three  groups,  how  the  coefficient  of  fatigue  is 
vastly  different  in  dementia  prsecox  from  normal  individuals  and 
alcoholics. 

Comparison  of  Individual  Work  Curves 

In  Fig.  2  we  have  shown  a  typical  curve  from  the  groups  in- 
vestigated and  compared  with  a  normal  curve.^ 

The  curves  on  the  left  each  represent  the  average  of  five  days 
work  for  ten  minutes  per  day  uninterrupted.  The  curves  on  the 
right  represent  the  average  of  five  days  work  with  a  pause  of 
five  minutes  after  the  fifth  minute  of  work.  This  period  is  rep- 
resented by  the  dotted  line.  The  curve  of  the  following  five 
minutes  represents  work  after  the  pause. 

In  the  normal  curve  a-/  it  will  be  seen  that  there  is  a  gradual 
tendency  of  the  curve  to  descend,  although  in  places  it  appears 
almost  horizontal.  However,  the  values  do  show  that  there  is  a 
decrease  in  amount  of  work  done  in  successive  minutes,  but  in 
tenths  so  that  it  cannot  be  accurately  shown  in  the  curve.  There 
is  a  certain  regularity  to  the  curve,  when  compared  to  that  of 
dementia  prascox.  Also  in  curve  a^II  (normal),  the  effect  of  the 
pause  is  distinctly  shown,  for  after  the  pause,  presented  by  the 
dotted  line,  the  curve  begins  at  a  much  higher  point  than  the  fifth 
minute,  and  a  trifle  higher  than  the  beginning  of  the  curve.  This 
curve  also  shows  the  gradual  decline  in  the  amount  of  work  done, 
both  before  the  pause  and  after  the  pause,  although  the  entire 
curve  after  the  pause  is  distinctly  higher  than  the  curve  of  the 
first  five  minutes.  As  we  said  above,  this  is  due  to  the  loss  of 
fatigue  during  the  rest,  and  also  to  the  residual  practice,  which 
has  shown  itself  in  the  period  following  the  rest. 

Comparing  this  curve  of  a  normal  individual  with  curve  b,  that 
of  a  dementia  praecox  case,  the  difference  between  the  two  is  at 
once  apparent.  In  the  first  place  one  sees  tremendous  variations 
in  the  curve  b-L    The  curve  sinks  very  low  at  the  fifth  minute, 

'  Curve  taken  from  figures  of  a  normal  person  given  by  Wilhelm  Specht 
in  Uber  klinische  Ermiidungsmessungen,  Archiv  fiir  die  Gesamte  Psy- 
chologie,  Band  III,  Heft  3. 


MENTAL   CAPACITY    IN    DEMENTIA    PRECOX 


133 


then  rises  again  and  ends  much  higher.  This  can  only  be  ac- 
counted for  by  the  variations  in  the  intensity  and  impulse  of  the 
will,  of  which  we  will  speak  more  in  detail  later.  When  we 
observe  the  curve  b-II,  representing  the  period  with  a  rest,  we 


Fig.  2. 


see  that  instead  of  the  sixth  minute  rising  distinctly  above  the 
fifth  minute  (before  pause)  the  curve  starts  at  a  much  lower 
level.  This  shows  that  the  rest  has  not  had  a  good  effect  upon 
the  work  of  the  patient,  but  has  had  a  decidedly  unfavorable 


134  MENTAL   CAPACITY   IN   DEMENTIA    PR/ECOX 

influence  on  the  after  work.  It  also  shows  that  there  was  either 
no  fatigue  present  or  that  if  present,  it  was  not  compensated  dur- 
ing the  pause.  And  from  what  we  know  clinically  of  dementia 
prsecox  cases,  especially  the  catatonic  forms,  the  first  supposition 
is  the  correct  one.  The  sinking  of  the  curve,  then,  is  not  due  to 
fatigue,  but  to  fluctuation  and  variations  in  the  intensity  of  the 
will ;  although  apparently  working  steadily  along,  the  curve  shows 
that  the  will  is  far  from  being  under  the  control  of  the  patient. 
In  curve  C-I  and  //,  that  of  a  patient  with  alcoholic  hallucinosis, 
we  find  very  little  deviation  from  the  normal.  The  fatigue  is 
shown  by  the  gradual  descent  of  the  curve.  And  after  the  pause 
or  rest,  the  curve  begins  at  a  much  higher  level,  not  only  as  com- 
pared with  the  fifth  minute,  but  with  the  first  minute  as  well. 
While  these  curves  are  shown  as  typical  of  the  three  groups  under 
discussion,  it  must  not  be  supposed  that  all  of  the  cases  in  the 
three  groups  would  show  similar  curves  respectively  in  each 
group.  There  are  wide  variations  in  individuals  of  the  three 
groups,  but  at  the  same  time  the  average  of  the  curves  of  each  of 
the  three  groups  will  show  distinct  differences  from  each  separate 
group.  Especially  will  this  be  shown  later  when  different  fac- 
tors are  considered,  such  as  fatigue,  impulse  of  the  will,  daily 
increase  in  work,  total  amount  of  work  done,  etc. 

Combined  Average  Work  Curves   (Fig.  3) 

An  effort  was  made  to  show  the  average  curve  of  each  group, 
but  the  results  of  averaging  all  the  curves  of  one  group  was  not 
a  representative  curve,  as  the  variations  of  each  individual  curve 
would  balance  that  of  the  others  of  the  same  group,  and  the 
result  was  not  a  representative  curve.  But  this  difficulty  was 
overcome  by  Professor  Kraepelin,  when  he  suggested  curves  made 
up  of  the  relation  of  each  minute  to  the  first  minute,  without  any 
reference  to  actual  values.  So  the  combined  work  curves  were 
constructed  as  shown  in  Fig.  3.  Here  the  peculiarities  of  each 
group  were  represented  graphically,  and  the  result  was  startling. 
The  work  of  the  first  minute  in  each  group  is  the  basis  for  com- 
puting the  proportion  of  every  other  minute  to  the  first.  The 
standard  value  of  the  first  minute  is  placed  at  100.  The  value  of 
the  other  minutes  are  computed  by  logarithms  in  terms  of  the  first 


MENTAL   CAPACITY   IN    DEMENTIA   PRECOX 


135 


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136  MENTAL   CAPACITY    IN    DEMENTIA   PRECOX 

minute,  or  100.  Thus,  in  the  normal  curve,  constructed  from 
the  average  proportion  of  the  25  individuals,  shows  the  second 
minute  to  be  92.4,  in  other  words,  the  relation  of  the  average  of 
the  first  minute  to  the  relation  of  the  average  of  the  second  min- 
ute of  all  individuals,  is  as  100  to  92.4,  and  so  on  for  the  rest  of 
the  curve.  And  the  same  method  was  used  for  the  other  two 
groups.  It  will  be  noticed  that  at  the  fifth  minute  the  curve  di- 
vides, one  curve  continues  on,  and  the  other  is  represented  by  a 
dotted  line.  This  division  of  the  curve  is  to  show  the  difference 
in  the  relations  of  the  last  five  minutes  without  a  pause  (the 
uninterrupted  line),  and  the  last  five  minutes  following  the  pause 
or  rest,  as  shown  by  the  dotted  line.  The  first  five  minutes  of 
each  day  is  taken,  as  the  work  is  uniform  until  the  end  of  the 
fifth  minute,  when  on  one  day  a  pause  intervenes,  and  on  alter- 
nate days  no  pause  is  allowed.  In  other  words,  the  first  five 
minutes  of  all  curves  of  an  individual  group  are  obtained  under 
similar  conditions,  while  after  the  fifth  minute,  the  pause  makes 
a  distinction.  And  the  effect  of  the  pause  is  graphically  shown 
by  the  curve  represented  by  the  dotted  line.  In  the  normal  it 
will  be  seen  that  the  curve  gradually  descends,  although  there  are 
some  slight  variations  throughout  the  ten  minutes  work  without 
a  pause.  (Note  the  abscissa  indicates  the  minute  of  work,  the 
ordinate  the  proportions  of  each  minute  to  the  first  minute.)  The 
sixth  minute  (dotted  line)  is  separated  from  the  sixth  minute 
(straight  line)  by  a  considerable  space.  In  the  former  the  value 
is  97,  in  the  latter  88.  This  difference  represents  the  direct  effect 
of  the  pause,  and  it  will  be  noted  that  the  course  of  the  curve 
(dotted  line)  continues  at  a  much  higher  level  than  the  other 
curve.  This  corresponds  with  the  typical  normal  curve  in  Fig.  i. 
Another  peculiarity  is  that  in  the  last  two  minutes  of  the  lower 
curve  there  is  a  slight  rise,  showing  the  effect  of  the  straining 
of  the  will  by  a  distinct  effect  to  overcome  the  fatigue.  As  the 
fatigue  after  the  pause  is  less,  we  do  not  have  this  strain  at  the 
last,  and  the  curve  sinks  during  the  last  minute  of  work. 

The  difference  between  the  values  of  the  first  and  second  minute 
represents  the  impulse  of  the  will  (Antrieb).  As  we  all  know, 
when  one  has  a  certain  task  to  perform  one  goes  at  it  with  a 
strong  impulse  to  accomplish  the  task,  and  this  tension,  as  soon 
as  the  work  is  started,  lets  up,  and  the  second  minute  shows  a 


MENTAL   CAPACITY   IN    DEMENTIA   PRECOX  1 3/ 

considerable  decrease  in  the  amount  of  work  done  as  compared 
with  the  first  minute,  or  at  the  beginning  of  the  task.  And  the 
difference  between  the  sixth  and  seventh  minute  after  the  pause 
(dotted  Hne)  represents  the  impulse  of  the  will  after  the  pause. 
This  is  not  so  great  as  the  impulse  at  the  beginning,  as  through 
practice  the  task  is  known,  and  one  does  not  strain  the  will  to 
accomplish  the  work  at  hand  to  such  an  extent  as  first. 

When  we  observe  the  combined  curve  of  the  dementia  praecox 
cases,  we  at  once  notice  a  marked  contrast  with  the  normal.  The 
same  variations  and  fluctuations  in  the  curve  are  seen  as  were  seen 
in  the  typical  curve  of  dementia  praecox  in  Fig.  i,  b.  But  this  is 
a  composite  curve  of  the  twelve  cases  of  dementia  praecox,  and 
the  variations  would  be  lessened  rather  than  increased.  One  point 
of  difference  between  this  and  the  normal  curve  is  the  sudden 
sinking  of  the  curve  from  the  fourth  to  the  fifth  minute.  Here 
is  a  drop  from  96.5  to  84  and  then  a  sudden  rise  to  93  at  the  sixth 
minute.  As  seen  by  the  fluctuations,  the  question  of  fatigue  does 
not  come  into  consideration  at  all.  First,  because  there  are  two 
ascents  to  the  curve  following  this,  and  secondly,  because  the  sixth 
minute  after  pause  is  comparatively  very  little  above  the  sixth 
minute  without  any  pause. 

To  find  the  explanation,  then,  we  must  consider  the  will  which 
is  seriously  affected  in  dementia  praecox.  Here  the  defect  is 
graphically  demonstrated,  and  the  sudden  descent  of  the  curve 
can  be  ascribed  to  the  neglect  of  the  will  (Vernachlassigung  des 
Willens)  or  deflection  of  the  will. 

The  fluctuations  of  the  curve  in  the  last  five  minutes  (without 
pause)  is  remarkable  and  is  explained  by  the  difficulty  of  keeping 
dementia  praecox  cases  at  a  given  task.  The  apathy  shown  clin- 
ically is  here  graphically  demonstrated. 

The  course  of  the  curve  after  the  pause  (dotted  lines)  also 
bears  out  the  statement  that  there  is  little  fatigue,  and  the  curve, 
instead  of  remaining  at  a  higher  level  after  the  pause,  actually 
sinks  lower  than  the  continuous  curve.  So  that  from  this  curve 
three  facts  are  demonstrated:  (i)  The  absence  of  fatigue,  (2)  the 
irregularity  of  the  tension  of  the  will,  (3)  the  absolute  deflection 
of  the  will.  The  impulse  of  the  will  at  the  onset  of  the  work  is 
much  less  than  in  the  normal  and  much  less  than  that  in  alcoholics. 
The  third  curve  represents  the  composite  curve  of  the  alcoholics. 


138  MENTAL   CAPACITY   IN   DEMENTIA   PRECOX 

This  type  of  patients  investigated  were  variable,  and  some  -were 
practically  normal,  especially  those  recovering  from  delirium 
tremens.  The  others  belonged  to  the  class  of  alcoholic  halluci- 
nosis and  alcoholic  paranoic  conditions. 

This  curve  does  not  differ  materially  from  the  normal,  except 
in  the  height  of  the  curve  at  the  sixth  minute  after  the  pause. 
Here  the  curve  starts  at  103  or  3  points  above  the  height  at  the 
beginning  of  the  work  and  six  points  above  the  same  value  in 
the  normal  curve. 

This  increase  in  the  amount  of  work  done  in  the  sixth  minute 
in  alcoholics  over  the  normal  is  explained,  not  so  much  by  the 
fatigue,  but  by  the  fact  that  during  the  pause  the  residual  idea  of 
the  work  is  lost,  and  they  start  in  with  a  marked  tension  of  the 
will,  assisted  by  the  residual  practice-effect  (Ubungs  Nachwirk- 
ung).  And  they  seem  to  have  lost  the  impression  of  the  work 
during  the  pause,  so  that  it  is  in  one  sense  a  new  task  to  them, 
while  in  the  normal  the  memory  impression  is  more  lasting,  and 
the  normal  does  not  start  out  with  such  a  great  impulse  to  accom- 
plish the  task. 

Total  Mental  Capacity 
(Absolute  Leistung) 

We  obtain  the  values  for  the  total  capacity  for  mental  work  or 
the  absolute  ability  for  work  in  the  various  groups,  by  taking  an 
average  of  the  total  number  of  additions  performed  in  the  first 
five  minutes  for  the  ten  days.  It  is  impossible  to  take  the  average 
of  the  whole  ten  minutes  for  on  alternate  days  a  rest  or  pause  is 
allowed  after  the  fifth  minute,  and  consequently  the  last  five  min- 
utes of  work  cannot  be  used  in  computing  the  amount  of  work 
performed  by  the  individuals  of  the  various  groups. 

By  observing  Chart  I  we  will  see  the  values  for  the  total  mental 
capacity  represented  in  a  graphic  manner.  The  values  are  repre- 
sented by  columns  for  comparison,  and  it  will  be  seen  that  there 
is  very  little  difference  in  the  amount  of  work  done  by  the  three 
groups.  The  values  for  the  normal  group  vary  from  263  to  104, 
and  the  average  for  the  group  is  185.  In  the  dementia  praecox 
group  the  variations  are  between  wider  limits,  i.  e.,  from  289  to 
92,  but  the  average  is  considerably  lower  than  in  the  case  of  the 
normal  group,  viz.,  165. 


MENTAL   CAPACITY    IN    DEMENTIA    PRECOX  1 39 

In  the  alcoholic  group  the  variations  are  between  much  wider 
limits,  i.  e.,  from  323  to  96,  and  the  average  for  the  group  is  i88, 
a  trifle  higher  than  the  normal  average,  while  the  average  for  the 
dementia  praecox  group  is  much  below  that  of  the  normal  and 
alcoholic  groups.  One  is  at  first  surprised  that  the  difference  is 
so  slight.  But  when  we  consider  the  clinical  features  of  dementia 
praecox,  this  finding  is  not  so  surprising,  and  the  clinical  and  psy- 
chological facts  are  in  harmony.  We  know  that  frequently  in 
this  class  of  cases  the  intellectual  defects  are  slight,  and  often 
absent  for  many  years,  so  that  the  patients  afflicted  with  this  dis- 
ease retain  to  a  considerable  degree  their  intellectual  faculties, 
although  profound  disturbance  of  other  psychic  fields  (emotion, 
will  and  ideation)  are  present  and  prevent  the  patient  from  living 
a  normal  mental  life. 

We  will  demonstrate  later  that  the  disturbance  in  dementia 
praecox  is  to  be  found  in  other  fields  than  the  purely  intellectual. 
Of  course,  in  the  end  stages  of  the  disease  this  field  also  suffers 
and  we  see  cases  with  profound  mental  deterioration.  The 
alcoholic  group  exhibited  only  slight  deviations  from  the  normal, 
and  none  of  the  cases  were  demented  so  that  the  intellectual 
capacity  does  not  differ  materially  from  the  normal.  So  this  fact 
is  in  absolute  harmony  with  the  clinical  symptoms  of  the  disease. 

In  connection  with  the  total  intellectual  capacity  we  must  con- 
sider the  daily  increase  in  the  amount  of  work  performed  through 
practice  (Ubung).  This  is  shown,  first,  in  Chart  I,  now  under 
consideration,  and  is  represented  by  the  lined  columns  at  the  base 
of  the  solid  block  columns.  This  is  illustrated  in  this  manner  so 
that  one  can  compare  the  daily  increase  with  total  capacity  in  indi- 
vidual cases  of  the  three  groups.  And  the  figures  given  in  the 
squares  represent  the  values  of  the  daily  increase  in  each  case. 
The  values  are  shown  graphically  again  in  Chart  2  for  a  com- 
parison of  the  three  groups. 

By  comparing  the  values  in  Chart  i  it  will  be  seen  that  there  is 
considerable  variation  between  the  amount  of  work  performed, 
and  the  daily  increase  through  practice  in  different  individuals. 
Thus,  in  the  normal  group  the  highest  daily  increase  ( 14)  occurs 
in  two  cases,  in  one  where  the  total  work  value  is  180,  somewhat 
below  the  average,  and  in  the  other  with  a  total  work  value  of 


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142  MENTAL   CAPACITY   IN   DEMENTIA    PRECOX 

230,  somewhat  above  the  average  of  185.  The  variations,  how- 
ever, are  not  so  marked  as  in  the  dementia  prsecox  and  alcoholic 
groups.  In  the  normal  the  average  for  the  first  14  cases,  with 
work  values  above  the  average  for  the  group,  is  10.2,  while  the 
average  for  the  11  cases  below  the  group  average  (185)  is  9,  and 
by  comparing  Chart  2  the  average  daily  increase  is  9.5  for  the 
normal  group.  Hence,  in  general  we  can  state  that  in  the  normal 
group  the  daily  increase  is  proportionate  to  the  total  work  per- 
formed. 

In  the  dementia  praecox  group  we  see  more  variation  in  the 
relations  of  these  values.  The  lowest  daily  increase  2.7  is  found 
in  next  the  highest  column,  230,  and  the  highest  daily  increase, 
12.4  in  column  178,  somewhat  above  the  average  165.  By  com- 
paring the  daily  increase  in  cases  where  the  work  values  are  above 
the  average,  we  find  almost  the  same  condition  as  in  the  normal. 
The  average  of  daily  increase  in  five  cases  above  the  group  aver- 
age of  work  values  is  8.5,  which  is  1.7  above  the  average  daily 
increase  for  the  group,  while  6.4  represents  the  average  of  the 
seven  columns  below  the  group  average.  So  that  it  can  also  be 
said  for  dementia  prsecox  that  the  same  conditions  are  demon- 
strated as  in  the  normal  regarding  the  proportion  of  daily  increase 
to  that  amount  of  work  done. 

In  the  alcoholic  group  the  variations  in  the  daily  increase  show 
much  greater  variations  than  either  dementia  praecox  or  normal, 
between  19.2  and  2.^,  and  the  average  9.5.  Again  considering  the 
cases  which  are  above  the  group  average,  we  find  six  cases  with 
an  average  of  11.6,  and  these  below  the  group  average  in  work 
values,  eight  cases  with  an  average  of  7.4.  Again  the  rule  as 
applied  to  the  normal  holds  good  for  alcoholics,  except  that  the 
difference  between  these  two  averages  is  4.2,  which  is  greater 
than  either  the  normal  or  dementia  praecox  groups. 

By  comparing  the  three  groups,  as  shown  in  Chart  2,  we  see 
that  the  normal  and  alcoholic  group  are  practically  the  same  (9.5, 
9.6),  while  dementia  praecox  falls  far  below,  6.8.  And  this  is  in 
harmony  with  the  facts  shown  in  Chart  i,  in  which  the  dementia 
praecox  group  shows  total  capacity  for  work  much  below  the 
normal  and  alcoholic  group. 


mental  capacity  in  dementia  precox  i43 

Effect  of  Practice  (Ubung) 

In  close  relation  to  the  total  intellectual  capacity  and  average 
daily  increase,  is  the  effect  of  practice,  in  fact,  the  total  amount 
of  work  accomplished  and  the  average  daily  increase  depend 
largely  upon  the  effect  of  practice.  The  effect  of  practice  is 
shown  in  average  daily  increase  in  the  amount  of  work  performed. 
In  Fig.  4  we  have  plotted  typical  curves  for  each  of  the  three 
groups.  These  curves  are  obtained  by  computing  the  amount  of 
work  performed  during  the  first  five  minutes  each  day,  and  mak- 
ing a  curve  for  these  values  for  the  ten  consecutive  days.  Here, 
again,  this  second  five  minutes  can  not  be  utilized  because  of  the 
pause  as  previously  explained. 

And  for  the  same  reason  that  we  could  not  use  actual  figures 
for  constructing  an  average  work  for  the  various  groups,  we  could 
not  construct  a  curve  representing  the  effect  of  practice.  There- 
fore somewhat  typical  curves  from  each  of  the  groups  are  selected. 
In  these  curves  the  abscissa  represents  the  days,  and  the  ordinate 
represents  total  amount  of  work  done  in  the  first  five  minutes 
on  each  day.  The  normal  curve  shows  a  steady  rise  with  slight 
variations  from  70  the  first  day  to  nearly  180  on  the  tenth  day. 
In  other  words,  this  individual  did  two  and  one  half  times  the 
amount  of  work  on  the  tenth  day  as  he  did  at  the  beginning,  or 
the  increase  was  250  per  cent.,  due  to  practice  and  familiarity  with 
the  work.  Of  course,  all  normal  curves  would  not  show  this 
tremendous  increase,  although  they  would  approximate  this  curve 
to  some  extent. 

The  curve  representing  a  case  from  the  dementia  prgecox  group, 
we  see  a  decided  difference.  It  will  be  noticed  at  first  that  the 
curve  begins  at  a  point  where  the  normal  ends,  that  is,  the  total 
amount  of  work  done  is  much  greater  than  in  the  normal  case. 
This  is  shown  on  Chart  i,  where  the  column  marked  230  is  next 
to  the  highest  column  of  this  group.  But  the  average  daily  in- 
crease is  only  2.7,  which  is  the  lowest  of  the  three  groups.  You 
will  notice  that  there  is  a  very  rapid  rise  for  the  first  four  days 
(from  170  to  275  or  160  per  cent,  increase),  then  a  sudden  drop 
to  210,  and  from  here  to  the  last  variation,  until  the  curve  ends  at 
245,  or  140  per  cent,  increase  over  the  work  done  in  the  first 
minute.     This  shows  graphically  the  well  known  clinical  symptom 


144 


MENTAL   CAPACITY   IN    DEMENTIA    PRECOX 


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MENTAL   CAPACITY    IN    DEMENTIA   PRECOX  1 45 

of  this  form  of  mental  disease,  that  is,  a  general  emotional 
apathy,  a  loss  of  interest  in  surroundings,  work,  pleasure,  etc. 
So  then  one  is  not  surprised  to  find  that  this  feature  of  the  disease 
is  shown  so  well  graphically  by  this  method.  And  this  curve  is 
not  the  most  pronounced  one  of  the  group,  but  is  fairly  repre- 
sentative of  the  group.  The  curve  of  the  alcoholic  patient  is 
nearly  the  same  as  the  normal,  and  is  also  fairly  representative 
of  this  group,  although  some  of  the  cases  show  more  variation. 

Susceptibility  to  Fatigue  (Chart  3) 
(Ermiidbarkeit) 

We  obtain  the  figures  for  the  coefficient  of  fatigue,  showing 
susceptibility  to  fatigue  by  considering  the  general  effect  of  the 
pause  upon  the  individual's  work.  This  method  was  explained 
in  the  first  part  of  this  paper,  and  will  not  be  elucidated  again. 

By  this  method  we  obtain  the  values  represented  by  the  columns 
in  Chart  3.  In  the  normal  group  we  see  variations  in  the  coeffi- 
cients from  I  to  17,  and  the  average  for  the  group  is  6.  It  will 
be  seen  that  no  negative  values  are  present,  as  in  the  dementia 
praecox  and  the  alcoholic  group.  In  the  normal  group,  without 
exception,  the  pause  or  rest  has  had  a  beneficial  effect  upon  the 
after  work,  as  we  saw  in  Fig.  3.  This  is  not  so,  however,  in  the 
dementia  praecox  group,  for  in  the  group  8  out  of  the  12  cases 
show  a  negative  coefficient  of  fatigue,  varying  from  5.1  to  i,  and 
are  represented  by  columns  extending  below  the  line  o.  The  aver- 
age for  the  group  is  only  i.  The  average  for  the  8  negative  cases 
is  — 2.8  This  result  is  rather  striking,  and  corresponds  to  the 
facts  explained  in  regard  to  curves  shown  in  Fig.  3,  only  here 
the  comparison  between  the  groups  can  be  more  distinctly  made. 
It  can  readily  be  seen  that  the  effect  of  the  rest  was  very  unfavor- 
able to  the  dementia  prjecox  group,  and  that  fatigue  was  not 
present  in  the  large  majority  of  cases. 

In  the  alcoholic  group  the  average  6.5  is  just  above  the  normal 
and  there  is  very  little  difference  in  the  coefficients.  However, 
we  have  3  negative  cases  out  of  14,  and  these  3  cases  were  of  the 
dull  stupid  type  so  often  seen  among  this  group.  In  both  groups 
(dementia  praecox  and  alcoholics)  the  cases  in  which  the  fatigue 
II 


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MENTAL    CAPACITY    IN    DEMENTIA   PRECOX 


147 


coefficient  was  negative,  were  also  the  cases  with  a  smaller  total 
capacity  in  comparison  with  other  cases  of  the  same  groups. 
In  Chart  4  the  values  representing  the  direct  effect  of  the  pause 


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are  shown.  We  have  explained  previously  the  method  whereby 
these  values  were  obtained.  Unfortunately,  I  was  unable  to  obtain 
in  the  normal  group  more  than  the  values  for  9  cases.     But  these 


148  MENTAL   CAPACITY    IN    DEMENTIA    PRECOX 

show  no  negative  values.  The  average  for  the  normal  group  is 
9.5,  which  is  considerably  below  the  average  for  the  alcoholic 
group,  viz.,  14.  And  this  is  also  shown  in  Fig.  3  by  the  height  of 
the  dotted  line  after  the  pause  where  it  reaches  103.  And  this 
has  also  been  explained  by  the  fact  that  in  the  alcoholic  cases, 
although  the  fatigue  values  are  not  much  above  normal,  yet  the 
work  after  the  pause  shows  an  increase,  probably  because  these 
patients  after  the  pause  have  lost  the  effect  of  the  work  given 
before  and  start  in  as  if  they  were  beginning  a  new  task.  By 
comparing  the  values  of  the  impulse  after  the  pause,  as  shown  in 
Chart  6,  we  find  that  in  alcoholics  the  average  for  the  group  is 
lighter  than  the  average  for  the  normal,  4.5  and  1.5,  respectively. 
And  from  these  facts  we  can  assume  that  the  intensity  of  the 
will  is  not  lost  as  soon  as  in  the  case  of  the  normal  group,  and 
in  consequence  of  this  the  alcoholics  go  to  work  after  the  pause 
with  greater  intensity  of  the  will,  and  the  values  of  the  work  in 
the  sixth  minute  after  the  pause  are  higher  than  in  the  normal 
group.  Also  the  readiness  for  work  is  lost  more  quickly  than  in 
the  normal  person,  as  explained  above. 

In  dementia  prsecox,  however,  during  the  pause,  a  different 
process  has  been  in  operation.  We  have  seen  that  no  great 
amount  of  fatigue  is  to  be  compensated  or  dissipated  by  the  rest, 
and  the  sudden  decrease  in  the  intensity  of  the  will  counterbalances 
whatever  recuperation  from  fatigue  might  have  taken  place. 
Thus,  the  work  of  the  last  minute  before  the  pause,  and  the  next 
minute  following  the  pause  (sixth  minute)  does  not  show  such  a 
great  difference  as  is  the  case  in  the  alcoholic  and  the  normal 
groups.  And  here  again  we  must  take  into  account  the  absence 
of  a  readiness  for  work,  the  presence  of  which  is  shown  in  alco- 
holics and  in  normals.  For  through  a  certain  indifference  to  the 
work  before  them  they  show  no  anxiety  to  go  ahead  and  do  their 
best.  Hence  in  Chart  4,  five  cases  out  of  12  are  represented  by 
negative  values,  and  the  average  for  the  group  is  only  5  com- 
pared with  9.5  and  14  for  the  normal  and  alcoholic  group 
respectively. 

From  these  charts  we  can  conclude,  then,  that  the  effect  of  the 
pause  or  rest  in  the  alcoholic  and  normal  groups  exerted  a  favor- 
able influence  upon  the  later  work,  especially  in  the  former  group. 
But  in  the  dementia  praecox  group  a  pause  of  the  same  length  had 


MENTAL   CAPACITY    IN   DEMENTIA   PRECOX  1 49 

a  very  unfavorable  effect  upon  their  work.  That  fatigue  is  greater 
in  alcoholics  than  in  normal  individuals  has  been  shown  by  other 
methods  and  experiments,  and  the  facts  found  here  corroborate 
the  views  of  other  investigators. 

Intensity  of  the  Will  (Impulse) 
Chart  5 

In  normal  individuals  the  intensity  of  the  will,  or  the  impulse 
of  the  will  is  influenced  by  four  factors,  as  follows:  (i)  In  the 
beginning  of  any  work  the  feeling  is  that  there  is  something  to 
be  overcome,  or  some  task  to  be  performed,  and  that  causes  a 
high  tension  of  the  will;  (2)  the  intensity  of  the  will  is  shown 
at  the  end  of  a  task  when  one  wants  to  do  as  much  as  possible 
before  one  finishes;  (3)  the  entrance  of  fatigue  causes  a  feeling 
of  weariness,  and  in  order  to  overcome  this  feeling  one,  so  to 
speak,  strains  the  will  to  greater  activity;  (4)  after  a  disturbance 
in  a  certain  period  of  work  or  task,  one's  attention  having  been 
distracted,  one  begins  again  to  work,  and  the  impulse  of  the  will 
is  again  shown.  This  is  shown  in  the  experiments  by  the  decrease 
in  amount  of  work  done  in  the  second  or  third  minute.  Compar- 
ing this  with  the  first  minute  before  and  after  the  pause,  we  must 
now  endeavor  to  find  how  the  normal  relation  is  disturbed  in  our 
abnormal  groups. 

We  see  that  the  initial  impulse  at  the  start  of  the  task  is  much 
greater  in  normal  than  in  alcoholics  or  dementia  praecox,  thus,  the 
values  are  29,  9  and  11,  respectively.  And  when  we  consider  that 
the  fatigue  in  the  dementia  praecox  group  is  very  small,  the  fact 
that  no  great  intensity  of  the  will  is  present,  these  two  facts  har- 
monize. By  observing  the  combined  work  curve.  Fig.  3,  we  will 
see  this  explained.  And  if  we  have  no  marked  impulse  or  tension 
of  the  will  the  only  way  to  explain  this  sudden  decrease  in  the 
third  or  fourth  minute  is  by  a  sudden  failure  of  the  tension  of  the 
will.  The  sudden  sinking  of  the  curve  to  83  in  dementia  prascox 
is  in  great  contrast  to  the  gradual  sinking  of  the  curve  in  alco- 
holics and  normal,  respectively  89  and  91.  These  latter  figures 
show  distinctly  the  effect  of  fatigue  which  has  overcome  the  ten- 
sion of  the  will.  And  we  have  seen  that  the  fatigue  is  very  small 
in  dementia  prascox  and  cannot  come  into  play  in  explanation  of 
the  sudden  sinking  of  the  curve. 


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MENTAL   CAPACITY    IN   DEMENTIA   PR^ECOX  I5I 

The  impulse  after  the  pause  shows  two  facts :  First,  that  during 
the  pause  the  fatigue  has  been  compensated  in  the  alcoholics,  and 
in  consequence  we  see  a  tremendous  rise  in  the  curve  after  the 
pause.  The  curve  rises  to  103,  which  is  higher  than  in  the 
start  of  the  task,  and  the  tension  of  the  will  is  not  as  high  as  at 
the  start.  How  is  it  in  dementia  praecox?  We  have  seen  that 
we  have  a  lesser  intensity  of  the  will,  and  therefore  less  fatigue, 
also  a  sudden  sinking  of  the  curve  in  the  fourth  minute.  And  we 
have  an  apparent  high  point  of  the  curve  after  the  pause,  but  only 
to  95.6,  which  is  very  much  below  the  alcoholics.  And  during  the 
pause  no  recovery  has  taken  place,  and  the  work  after  the  pause 
is  less  than  the  alcoholics.  Then  follows  again  the  sudden  failure 
of  the  tension  of  the  will.  The  pause  has  been  unfavorable,  for 
the  amount  of  work  done  after  the  pause  falls  below  the  amount 
of  work  done  without  a  pause  (see  curve.  Fig.  3).  Again  we 
must  take  into  account  the  readiness  for  work. 

We  must  conclude  that  in  both  groups  a  rapid  disappearance  of 
the  readiness  for  work  has  taken  place  during  the  five  minute 
pause,  and  in  normal  this  is  explained  by  the  fact  that  at  the  start 
of  the  work  the  normal  person  shows  a  great  deal  of  interest,  but 
after  a  short  pause  of  five  minutes  the  tension  of  the  will  has 
decreased  considerably  compared  with  the  tension  before  the 
pause.  We  know  from  experience  (although  such  a  fact  has  not 
been  established  experimentally)  that  normal  persons  hold  the 
readiness  and  interest  for  work  during  a  short  pause.  And  when 
they  again  begin  to  work  they  have  the  feeling  that  the  task  is 
not  so  difficult  because  they  know  what  they  have  to  do.  There- 
fore, they  do  not  exert  themselves,  and  the  amount  of  work  done 
by  the  normal  after  the  pause  is  much  less  than  that  performed 
by  the  alcoholics.  Also,  at  the  end  the  curve  sinks,  while  the 
curve  without  pause  rises  a  little  bit  because  of  practice  and 
familiarity.  And  we  conclude  (i)  that  the  tension  of  the  will 
before  and  after  the  pause,  which  in  dementia  praecox  and  alco- 
holics has  very  nearly  the  same  value,  is  caused  by  the  fact  that 
the  readiness  for  work  is  rapidly  lost  during  the  pause,  and  they 
begin  to  work  after  the  pause  just  as  if  they  had  a  new  piece  of 
work  to  do.  While  the  great  difference  of  the  normal  will  tension 
before  and  after  the  pause  is  due  to  the  fact  that  this  readiness 


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MENTAL    CAPACITY   IN   DEMENTIA   PRECOX  1 53 

for  work  has  not  disappeared,  they  are  prepared  for  the  task  at 
hand. 

It  can  be  demonstrated  by  experiment  that  after  pauses  or  rest 
periods  of  different  lengths  that  the  readiness  for  preparedness  for 
work  in  normal  also  is  lost,  and  the  tension  of  the  will  is  grad- 
ually increased  when  the  time  of  the  pause  is  lengthened. 

Second.  That  the  increase  in  the  work  done  after  the  pause  in 
alcoholics  is  due  to  the  dissipation*  of  fatigue  during  the  pause,  and 
also  the  higher  tension  of  the  will.  In  dementia  prsecox  the  total 
capacity  is  not  so  high  as  in  alcoholics,  but  the  impulse  of  the  will 
is  about  the  same  as  before  and  after  the  pause,  because  no  fatigue 
has  been  counterbalanced,  and  the  readiness  for  work  has  disap- 
peared. The  irregular  course  of  the  work  curve,  now  high,  now 
low,  shows  distinctly  the  fluctuation  of  the  tension  of  the  will. 

In  Chart  6  we  have  illustrated  the  impulse  of  the  will  after  the 
pause.  What  we  have  said  regarding  the  work  curves  in  Fig.  3 
is  corroborated  by  the  facts  deduced  from  this  chart.  In  the 
normal  group  we  have  3  cases  out  of  29  showing  negative  values, 
and  the  average  for  the  group  is  only  1.5.  In  the  dementia  prsecox 
group  there  are  only  2  negative  values  out  of  12  patients  exam- 
ined, and  in  the  alcoholic  group  only  2  negative  values  out  of  14 
patients  examined.  The  average  for  the  dementia  praecox  group 
is  here  shown  to  be  higher  than  the  other  2  groups,  or  6.5  com- 
pared to  1.5  normal  and  4.5  alcoholic.  And  this  greater  value  for 
dementia  praecox  as  compared  with  the  normal  and  alcoholics  is 
only  apparent,  or  when  we  consider  the  space  between  the  sixth 
minute  dotted  line  and  sixth  minute  full  line  in  the  3  groups.  In 
Fig.  3  this  increase  is  explained.  It  is  not  that  the  cases  of 
dementia  praecox  do  so  much  more  work  after  the  pause,  or  that 
the  impulse  is  greater,  but  the  sinking  of  the  curve  before  the 
pause  due  to  the  neglect  of  the  will  to  act,  accounts  for  this  light 
average  in  dementia  praecox. 

Conclusions 

By  the  simple  experimental  procedure  outlined  in  this  paper, 
we  have  shown : 

I.  That  the  disturbance  of  the  will  is  the  most  important 
symptom  of  Dementia  Praecox. 

'  Erhohlung. 


154  MENTAL   CAPACITY   IN    DEMENTIA   PRECOX 

2.  Because  of  this  defect  of  the  will,  the  rest  from  work,  so 
beneficial  to  normal  individuals,  and  the  alcoholic  cases,  has  an 
unfavorable  influence  in  Dementia  Praecox. 

3.  The  effect  of  practice  in  Dementia  Praecox  is  of  much  less 
value  than  in  normal  persons  and  alcoholic  cases,  which  conforms 
to  the  general  apathy  shown  in  Dementia  Praecox  cases. 

4.  Absolute  deflection  of  the  will,  a  prominent  symptom  in 
Dementia  Praecox,  is  shown  by  this  method. 

5.  Fatigue  is  absent  in  Dementia  Praecox,  and  greater  in 
alcoholics  than  in  normal  persons. 

6.  Absolute  mental  capacity,  as  shown  by  the  amount  of  work 
performed,  varies  but  little  in  the  three  groups,  being  less  in 
Dementia  Praecox  than  in  the  other  two. 

7.  That  the  daily  average  increase  in  the  individual  cases  is 
proportionate  to  the  total  amount  of  work  performed,  is  true  of 
the  three  groups. 

8.  That  the  experimental  results  agree  with  the  clinical  symp- 
toms of  Dementia  Praecox  and  Alcoholic  Insanity. 


THE   RELATIONSHIP   OF    HYSTERIA,    PSYCHAS- 
THENIA,  AND  DEMENTIA  PRECOX 

By  Adolf  Meyer,  M.D. 

PROFESSOR  OF  PSYCHIATRY,   JOHNS    HOPKINS   UNIVERSITY 

A  report  of  two  cases  furnishes  the  material  for  our  discus- 
sion ;  one  of  undoubted  hysteria  in  which  a  catatonic  dementia 
praecox  supervened ;  and  a  case  of  psychasthenia  with  obvious 
deterioration.  Unfortunately  the  material  for  a  discussion  of  the 
present  status  of  the  conceptions  of  hysteria,  psychasthenia,  etc., 
would  prove  too  long  even  if  I  should  limit  myself  to  giving  the 
main  facts,  in  view  of  the  tremendous  confusion  that  exists  owing 
to  the  ease  with  which  programmes  and  definitions  are  launched, 
and  owing  to  the  fact  that  as  a  rule  the  contentions  are  made 
without  documentation  by  actual  records.  To  my  regret  I  also 
must  abstain  from  the  publication  of  my  two  cases  in  full,  in  the 
form   in  which   alone  they   would   be  wholly   convincing. 

Suffice  it  to  say  that  the  first  case  presented  an  hysterical  hip 
for  one  year  at  1 1  ;  a  classical  hysterical  paraplegia  with  con- 
vulsions for  one  year  at  21,  another  four  months  of  hysterical  con- 
vulsions and  spinal  and  ovarian  hyperesthesia  at  23 ;  finally  at  28, 
a  psychosis  of  the  character  of  hysterical  delirium,  with  a  relapse 
which  passed  into  a  simple  stupor;  after  one  year  the  patient  was 
submitted  to  an  aggressive  thyroid  treatment,  passed  into  an 
exhausting  excitement,  and  after  a  few  months  into  a  classical 
catatonic  stupor  lasting  several  years  and  relaxed  but  gradually. 
Each  of  the  above  steps  set  in  on  the  ground  of  decided  strains ; 
the  development  was  fairly  consistent  and  the  residual  after  about 
fifteen  years  since  the  first  outspoken  psychosis,  a  condition  of 
nursing  a  "  pain  "  or  a  "  disease  "  in  the  spine,  stereotyped  man- 
ners, soliloquies  in  imaginary  settings,  but  in  the  main  a  slow 
response  to  efforts  to  reestablish  a  certain  adaptability  to  her  home 
environment  and  to  simple  home  interests. 

The  second  case  is  that  of  a  young  man  of  27,  as  a  boy  an 
indiscriminate  reader  and  imaginative,  slightly  odd  at  college,  with 
a  growing  obsession  of  incompleteness  of  his  toilet,  the  brush- 

155 


156        HYSTERIA,    PSYCHASTHENIA   AND   DEMENTIA    PRECOX 

ing  of  the  teeth  and  the  drying  after  the  bath — a  feehng  of  damp- 
ness, a  desire  to  rub  himself  dry — incompleteness  and  indecision 
are  the  patient's  own  words  for  his  condition.  The  ruminative 
episodes  have  become  more  and  more  automatic  and  they  domi- 
nate the  patient's  life  with  undeniable  dilapidation  of  all  capacity 
of  application  and  interest. 

In  teaching  we  can  present  the  first  case  as  one  showing  that 
plain  hysteria  does  not  protect  against  dementia  prsecox,  or  is  not 
incompatible  with  it,  and  more,  namely,  that  the  mechanism  can 
become  progressive. 

The  second  case  shows  that  the  simple  deterioration  may  carry 
with  it  the  picture  of  psychasthenia,  feeling  of  incompleteness  and 
indecision  and  automatism,  and  practically  no  other  trait,  under 
which  conditions  we  must  nevertheless  treat  the  disorder  like  one 
of  psychasthenia. 

The  relative  inaccessibility  of  both  cases  makes  it  difficult  to 
reconstruct  the  whole  picture  of  evolution  as  well  as  was  done 
in  Dr.  Hoch's  cases.  But  they  are  suggestive  at  least  as  a  foun- 
dation to  the  question  of  the  relation  of  hysteria,  psychasthenia 
and  dementia  prsecox. 

For  any  discussion  of  such  a  relation  we  should  review  what 
we  would  accept  as  safe  ground  concerning  the  entitiesv  From 
the  point  of  view  of  teaching  it  would  be  desirable  to  keep  the 
three  entities  clearly  apart  if  that  agrees  with  the  facts.  From 
the  point  of  view  of  constructive  work  and  analysis,  it  is  better 
to  make  the  most,  not  necessarily  of  the  identification  with  some 
dogmatic  compound  picture  which  is  sure  to  be  open  to  unwar- 
ranted twists  by  extraneous  factors,  but  rather  of  the  working 
factors  or  determining  conditions  that  constitute  the  deviation 
in  specific  cases,  and  the  modifiability  of  the  conditions.  This 
constructive  method  is  available  in  terms  of  reaction-types  rather 
than  of  disease  entities.^ 

The  issue  is  a  demand  for  safety  and  clearness  in  using  the  facts 
at  hand,  a  demand  to  work  with  what  the  case  actually  presents 
rather  than  through  identification  with  a  compound  picture  which 
we  do  not  see  and  have  to  take  on  authority,  with  inevitable  va- 
rieties of  definitions  (I  merely  refer  to  Dr.  Dana's  recent  effort 

^  Compare  the  Problems  of  Mental  Reaction-Types,  Mental  Causes  and 
Diseases,  Psycholog.  Bulletin,  Vol.  V,  245-261. 


HYSTERIA,    PSYCHASTHENIA   AND  DEMENTIA   PRECOX        1 57 

to  limit  hysteria  and  to  create  other  types).  The  synthetic  method 
is  also  more  apt  to  disclose  factors  worth  knowing  for  prophy- 
laxis, and  can  be  taught  as  readily  and  efficiently  for  work  as  the 
other,   although  perhaps  not  as  easily   for  examinations. 

The  issue  then  is  what  reaction  is  at  work?  What  are  the  de- 
termining conditions?  What  is  their  modifiability?  What  are 
the  alternatives  of  prospect  and  their  determination? 

In  this  respect  the  Freud-Jung  conceptions  command  most  at- 
tention, but  they  are  to-day  largely  emphasis  of  a  portion  of  the 
situation.  My  personal  preference  is  for  a  broad  formulation  of 
the  problems  in  terms  of  substitutive  activity. 

All  biological  function  is  an  adaptation  which  demands  for  its 
safe  expression  a  statement  of  (i)  the  determining  conditions, 
(2)  the  form  of  the  reaction,  and  (3)  the  result  or  terminal  con- 
dition. 

Among  the  adaptative  disorders  which  occupy  us  we  do  well  to 
try  and  make  a  fairly  clean-cut  distinction  between  simple  insuf- 
ficiency such  as  we  see  in  imbecility  and  those  disorders  which 
tend  to  be  progressive  and  cumulative.  Simple  insufficiency  may 
make  impossible  certain  reactions,  but  need  not  expose  the  indi- 
vidual to  destructive  false  attempts.  The  borderland  between 
imbecility  and  positive  substitutive  reactions  begins  where  the  in- 
dividual does  not  merely  fail  to  react  but  uses  poorly  planned  and 
ill-adapted  make-shifts,  such  as  tend  to  undermine  the  develop- 
rjient  or  maintenance  of  healthy  instincts. 

We  deal  in  the  first  place  with  a  great  number  of  individuals 
with  non-systematized  constitutional  inferiority,  forming  the  bor- 
derland between  imbecility  and  the  essentially  pathological  sub- 
stitutive reaction  types. 

The  next  level  of  reaction  is  the  neurasthenic  which  according 
to  Dejerine  and  Moebius  may  be  looked  upon  as  the  common 
source  of  the  other  neuroses,  or  if  you  wish  to  put  it  the  other 
way,  the  prodromal  type  of  many  further  developments.  The 
hypochondriacal  reaction  type  would  be  closely  connected  with  it ; 
the  psychasthenic  with  its  ruminations  and  obsessions  and  auto- 
matisms and  panics  would  form  another  branch.  The  hysterical 
reaction  type  with  its  submersion  and  conversion  into  most  dis- 
tinct examples  of  substitutive  reactions,  forms  the  group  which 
more   than   any  other  occupies  the  physician   because  it   shows 


158        HYSTERIA,    PSYCH  ASTHENIA   AND   DEMENTIA   PRECOX 

US  clearly  the  involvement  of  the  physical  component  of  our 
mental  activity. 

Psychology  is  but  reluctantly  coming  to  size  up  its  data  in  terms 
of  conduct  and  behavior,  with  due  attention  to  the  actual  physical 
component.  We  find  further  the  merely  dilapidating  or  dis- 
tinctly incongruous  reaction  types  marking  the  tendency  to  dete- 
rioration ;  the  scattered  fantastic  ruminations  or  the  tense  cata- 
tonic types,  or  the  sham  consistency  of  the  paranoic  development. 
Quite  a  few  paranoic  conditions  belong  to  this  group,  whereas  the 
manic-depressive  reaction  type  would  in  many  instances  remain 
more  or  less  doubtful  in  its  position  and  seem  to  be  more  akin  to 
the  not  clearly  psychologically  determined  epilepsy  series  of  physi- 
ological fluctuations.  As  all  biological  terms,  such  a  conception  as 
substitutive  activity  has  its  specially  appropriate  centers  of  utility 
and  it  shades  off  into  domains  where  it  is  less  useful.  It  is  plain 
enough  in  the  psychasthenic  and  hysterical  symptoms  which  are 
plainly  substitutions  for  what  is  dodged. 

One  common  method  is  to  speak  of  distinct  "  diseases,"  and  I, 
without  mentioning  the  term  "  disease  "  especially,  would  indeed 
speak  of  "  pure  cultures  of  reaction  types,"  of  cases  in  which  a 
special  reaction  type  is  dominant,  and  of  cases  in  which  it  is  in- 
cidental or  subordinate.  The  terms  which  stand  for  the  formula 
of  specific  diseases  are  of  didactic  importance  and  especially  jus- 
tified, because  some  of  the  reactions  practically  exclude  one 
another  as  is  the  case  between  hysteria  and  psychasthenia, 
whereas,  other  combinations  are  compatible  and  produce  all  those 
transition  forms  which  resist  definition  as  units.  In  any  case  a 
definition  should  contain  the  essence  of  the  mechanism.  Dr. 
Dana  speaks  of  the  disease  hysteria  as  being  a  morbid  mental 
condition  in  which  ideas  or  emotional  stress  seriously  and  un- 
wittingly control  the  body  and  produce  more  or  less  permanent 
and  objective  morbid  states, — and  he  then  uses  as  the  protype 
those  cases  produced  by  railroad  accidents,  shocks  and  collisions 
and  alcoholism ;  i.  e.,  cases  in  which  the  non-psychic  nervous  dis- 
orders are  evidently  very  predominant  and  with  them  the  fre- 
quently bad  prognosis :  whereas  most  of  the  other  hysterias  are 
classed  with  the  psychataxias  or  psychasthenias  as  not  true 
hysteria.  It  ought  to  be  plain  that  unless  we  make  identification 
with  a  name  the  main  issue,  it  is  better  to  train  the  student  to  think 


HYSTERIA,    PSYCHASTHENIA   AND  DEMENTIA    PRECOX        I  59 

of  pure  and  impure  or  complicated  reaction  types  rather  than  of 
"  true  "  hysteria,  psychasthenia,  etc.,  making  a  disease  of  an  arbi- 
trarily limited  group  of  cases,  without  evidence  that  the  funda- 
mental definition  explains  these  cases  and  with  serious  reasons 
to  assume  that  really,  matters  not  mentioned  in  the  definition  give 
the  group  its  character.  It  is  especially  undesirable  to  accept  a 
set  of  nosological  units  put  forth  without  the  documental  ma- 
terial of  records  to  back  up  the  contentions  as  is  the  case  with 
Kraepelin. 

With  these  principles  in  mind  I  reserve  the  term  dementia 
praecox  to  the  essential  deteriorations  in  which  there  is  absolutely 
no  doubt  about  the  deterioration,  and  give  some  descriptive  term 
to  the  reaction  type  at  hand,  hysterical,  psychasthenic,  hebephrenic, 
catatonic,  paranoid,  or  whatever  designates  the  mechanism  as  long 
as  deterioration  is  not  in  the  center.  I  do  this  with  all  the  more 
justification  if  I  consider  that  Kraepelin  in  his  book  says  that 
among  the  admissions  to  a  clinic  the  dementia  prsecox  cases  form 
but  a  slightly  higher  percentage  than  the  manic  depressive  ;  whereas 
Wilmanns  on  the  same  material  from  Heidelberg  reports  that 
between  1901  and  1905  the  rate  of  dementia  praecox  varied  be- 
tween 40  and  52  per  cent,  of  admissions,  and  the  manic-depressive 
ranked  between  11  and  16  per  cent.  The  question  thus  arises  very 
seriously — is  it  right  to  swell  the  issue  of  the  probable  or  possi- 
ble outcome  to  such  importance  as  to  become  the, leading  con- 
ception of  the  disease?  This  idea  is  in  the  ascendency  just  now. 
Two  years  ago  Janet  told  me  that  annually  a  number  of  hysterical 
patients  were  transferred  to  the  insane  wards  with  deterioration ; 
last  summer  he  felt  inclined  to  yield  to  the  tendency  to  mark  these 
cases  outright  as  cases  of  dementia  prascox.  In  his  descriptions 
of  psychasthenia,  however,  he  shows  a  number  of  cases  of  prog- 
ress to  deterioration  similar  to  my  second  case.  Peterson 
and  Jung  refer  to  the  fact  that  there  are  many  cases  of  de- 
mentia praecox  which  for  years  are  not  to  be  distinguished  from 
hysteria  and  that  a  large  number  of  catatonic  processes  were  for- 
merly called  degenerative  hysterical  psychoses.  Jung's  analysis 
shows  very  clearly  the  common  factor  in  the  developments  of  a 
hysterical  and  of  a  deterioration  reaction.  If  he  speaks  of  the 
stabilization  of  the  complex  he  gives  a  plain  expression  of  the 
plain  fact ;  but  he  yields  to  the  temptation  of  accounting  for  this 


l6o        HYSTERIA,    PSYCHASTHENIA   AND  DEMENTIA   PRJECOX 

stabilization,  etc.,  by  toxines,  a  method  which  to  my  mind  leaves 
too  readily  the  functional  ground  on  which  the  whole  investiga- 
tion has  prospered  and  the  plain  facts  are  exposed. 

I  thus  come  to  the  next  point  of  the  discussion ;  that  is,  what 
constitutes  the  unfavorable  reaction  type?  As  I  pointed  out 
in  a  paper  read  before  this  society  over  three  years  ago,  and 
again  in  the  Toronto  discussion^  we  have  strong  reasons  to  con- 
sider the  foundation  for  these  reaction  types  to  be  the  result  of 
conflicts  and  deviations  of  instincts,  and  in  cases  of  deteriora- 
tions we  find  invariably  that  the  complex-phenomena  occur  in  an 
especially  vulnerable  field,  or  denote  from  the  start  the  deficiency 
of  balancing  instincts. 

Why  should  a  patient  drift  so  strongly  into  more  or  less 
absurd  imaginations  pre-eminently  in  the  sexual  domain,  in  re- 
ligious elaborations  and  in  fantastic  spheres?  Why  should  there 
be  such  a  striking  tendency  to  ideas  of  reference  which  denote  so 
strongly  a  feeling  of  inferiority  of  action?  What  determines  the 
striking  tendency  to  feelings  of  passivity,  of  being  influenced, 
etc.,  in  the  automatisms,  which  the  more  hysterical  takes  in  a 
self-possessed,  not  in  a  passive  attitude?  A  careful  study  of 
the  cases  shows  the  ravages  of  habitually  incomplete  or  directly 
inadequate  and  ill-adapted  and  ill-controlled  reactions,  a  tendency 
away  from  the  contact  with  reality  and  self-correction,  a  scatter- 
ing of  the  personality,  with  or  without  the  sham  consistency 
which  we  see  in  the  paranoic  forms,  and  through  it  all  a  stultify- 
ing of  the  instincts  which  are  essential  for  balancing  in  the  com- 
plex demands  of  life.  We,  therefore,  attribute  a  pernicious  effect 
to  a  trauma  in  the  sense  of  Freud  and  Jung,  even  when,  instead  of 
its  merely  leading  to  the  hysterical  reaction  type,  it  plays  a  role 
in  an  actual  interference  of  development  of  instincts.  In  this 
respect  it  takes  little  skill  to  realize  how  different  the  sexual  evolu- 
tion of  the  hysterical  is  from  that  of  the  dementia  praecox  case; 
there  is  much  more  inferiority  or  miscarriage  of  function  in  the 
future  dementia  precox  case,  to  suggest  voices  or  electric  cur- 
rents in  the  womb,  or  the  imaginations  of  love  answered  by  a 
stranger  through  passive  movements  of  the  tongue.  In  all  this 
we  invariably  see  additional  interweaving  of  habit-deteriorations, 
ruminations  instead  of  youthful  pranks  and  of  a  rash  trial  and 

*  British  Medical  Journal,  September,  1906. 


HYSTERIA,    PSYCHASTHENIA   AND   DEMENTIA   PRJECOX         l6l 

rejection  method  of  the  more  wholesome  development,  with  its 
instinct  for  touch  with  reality.  And  beside  these  defects  we  see 
precocious  one-sided  moralizing,  top-heaviness,  leading  the  patient 
further  and  further  away  from  the  life  with  concrete  correc- 
tions. 

The  effect  of  the  spreading  into  ill-protected  domains  and  the 
determination  of  the  seriousness  of  such  combinations  is  easy  to 
demonstrate  in  the  question  of  masturbation,  which  to  this  day  is 
dealt  with  in  the  most  dogmatic  and  absurd  fashion  by  a  large 
number  of  physicians  who  think  they  can  settle  the  issue  by  the 
negation  of  all  importance,  and  the  mere  assumption  of  funda- 
mental defect  where  it  happens  to  lead  to  disaster.  Masturbation, 
like  the  use  of  alcohol,  must  be  judged  specially  in  every  case. 

It  will  be  the  task  of  a  publication  of  a  sufficient  number  of 
thoroughly  studied  cases  to  show  the  lines  of  cleavage  between 
deviations  of  instincts  which  do  and  others  which  do  not  tend  to 
become  progressively  destructive.  To  think  of  these  matters  in 
terms  of  auto-intoxication  is  not  ruled  out  if  such  a  relation  is 
demonstrated,  nor  should  we  of  course  be  satisfied  with  an 
abstract  statement  that  we  deal  with  conflicts  and  deterioration  of 
instincts ;  but  at  the  present  juncture  it  is  best  to  recognize  the 
probability  that  in  many  cases  a  number  of  factors  combine  and 
that  among  these  many  can  only  be  expressed  in  activities,  habits 
and  instincts  and  that  a  sweeping  over-simplifying  terminology 
obscures  the  clearness  of  observation  and  reasoning. 

Neurology  has  led  us  too  much  out  of  a  functional  appreciation 
of  developments.  It  reasons  largely  with  stationary  and  progres- 
sive focal  conditions  and  their  occasional  repair,  rather  than  with 
balancing  mechanisms,  such  as  we  must  work  with  in  psycho- 
pathology. 

The  conception  of  substitutive  reactions  brings  us  back  to  a 
normal  foundation  of  direct  activity  again.  It  frees  us  from  ex- 
cessive definitions  at  the  loose  end,  furthers  definition  of  the 
actual  situation  and  of  the  means  of  adaptation  available  in  the 
patient.  Instead  of  a  plan  of  identification  with  names  of  arbi- 
trary patterns  we  get  attention  to  the  facts  at  hand  without  arbi- 
trary expurgations.  We  can  see  and  teach  what  we  have  in  the 
pure  cultures  of  hysteria,  psychasthenia,  and  dementia  prascox, 
and  if  we  find  collaboration  of  special  factors,  we  have  a  place 

12 


1 62        HYSTERIA,    PSYCHASTHENIA   AND   DEMENTIA   PRECOX 

for  them  according  to  the  facts,  be  they  of  the  type  of  regulation 
of  conduct  and  behavior,  i.  e.,  mental,  or  infrapsychical,  toxic 
or  what  not. 

This  mode  of  presentation  can  be  made  just  as  simple  as  that 
which  works  with  disease-entities  and  much  more  just  and  espe- 
ially  much  more  valuable  in  plans  of  handling  the  case  and  in 
shaping  facts  for  prophylaxis. 


AN  EXPERIMENTAL  STUDY  OF  THE  OCULAR 

REACTIONS   IN   THE   PSYCHOSES,   FROM 

PHOTOGRAPHIC   RECORDS 

By  Allen  Ross  Diefendorf,  M.D. 

LECTURER   IN    PSYCHIATRY   IN    YALE  UNIVERSITY    MEDICAL   SCHOOL 

AND  Raymond  Dodge,  Ph.D. 

PROFESSOR   OF   PSYCHOLOGY   IN    WESLEYAN    UNIVERSITY 

Within  the  last  few  years  exact  knowledge  of  the  normal  move- 
ments of  the  eyes  has  made  rapid  advance,  particularly  in  Amer- 
ica, through  the  use  of  mechanical  and  photographic  registering 
devices.  Quantitative  information  is  now  at  hand  with  respect 
to  the  angle-velocity  (2,  3,  9)^  and  the  path  of  the  line  of  regard 
during  rapid  eye-movements  (4-6,  8,  10-16),^  the  accuracy,  sta- 
bility and  variability  of  fixation  under  a  considerable  variety  of 
circumstances  (4,  6,  8,  iQ-15),^  the  ocular  reaction-time  (8),* 
and  the  peculiar  modifications  of  eye-movements  which  consti- 
tute short-lived  motor  habits  (5),^  pursuit  movements  (7),^  co- 
ordinate compensatory  eye-movements  (7,  8),^  and  the  move- 
ments of  convergence  (12).^ 

The  ease  with  which  the  photographic  technique  can  be  adapted 
to  a  wide  variety  of  experimental  requirements,  together  with 
certain  peculiarities  of  the  eye-movements  themselves,  led  the 
writers  to  believe  that  a  comparative  study  of  the  eye-movements 
of  normal  and  insane  persons  might  be  made  a  fruitful  contri- 
bution to  our  experimental  knowledge  of  the  reactions  of  the 
insane. 

Such  a  comparative  study  might  well  find  its  basis  in  any  of  a 
large  variety  of  experimental  data.  The  present  investigation  was 
limited  to  three  main  problems,  which  were  relatively  clear  to  us, 
and  to  meet  which  we  framed  our  technique. 

The  difficulties  in  any  experimental  study  of  normal  psycho- 

^  Numbers  i  to  16  refer  to  the  bibliography  at  the  end  of  the  paper. 

163 


164  OCULAR   REACTIONS    IN    THE    PSYCHOSES 

physical  processes  are  serious  enough,  even  though  one  may  rely 
on  the  highest  degree  of  intelligent  cooperation  on  the  part  of  the 
subject.  In  the  study  of  abnormal  mental  life,  additional  diffi- 
culties arise  from  the  very  nature  of  the  object  of  investigation, 
in  direct  proportion  to  its  variation  from  the  normal.  As 
Kraepelin  cogently  observes,  lack  of  comprehension  of  the  ex- 
perimental test,  lack  of  ability  to  execute  it,  lack  of  interest, 
cooperation,  and  of  endurance,  all  conspire  to  increase  the  task 
of  the  experimenter  and  to  modify  the  value  of  his  results.  The 
consequent  demand  for  trustworthy  experimental  methods,  which, 
without  too  complicated  technique  or  too  unusual  demands  on  the 
patient,  shall  yield  quantitative  information  of  significant  varia- 
tions from  normal  reactions,  voices  at  once  the  need  and  the 
embarrassment  of  experimental  psychiatry.  These  demands  are 
met  in  part  at  least  by  the  reactions  of  the  eyes  as  they  are  known 
through  their  photographic  records. 

Eye-movements  are  neither  unusual  nor  difficult.  On  the  con- 
trary, the  ability  to  look  at  a  bright  object  which  appears  suddenly 
within  the  field  of  view  is  one  of  the  earliest  forms  of  motor 
organization  to  be  achieved,  and  it  is  retained  long  after  the 
ability  to  learn  new  and  complex  forms  of  reaction  is  irretrievably 
lost.  A  patient  will  naturally  look  at  a  suddenly  appearing  object 
when  he  could  learn  the  simplest  new  reaction  only  imperfectly 
and  with  enormous  waste  of  time. 

Moreover,  while  the  eye-movements  are  intimately  associated 
with  the  most  complex  mental  activities,  they  are  peculiarly  inac- 
cessible to  subjective  observation.  Even  the  best  trained  observers 
utterly  failed  by  introspection  to  discover  some  of  the  facts  of 
eye-movements  which  are  most  conspicuous  in  the  photographic 
records.  For  the  ordinary  man,  his  eye-movements  are  usually 
involuntary  and  unconscious ;  they  are  essentially  a  part  of  the 
mechanical  preadjustments  of  vision,  and  consciousness  is  con- 
cerned with  the  result  rather  than  the  preadjustments.  They  may 
on  occasion  be  consciously  initiated,  but  once  begun  they  are 
entirely  withdrawn  from  conscious  control.  This  effectually  pre- 
vents both  arbitrary  modifications  and  successful  simulation  of 
pathological  symptoms.  Moreover,  relative  uniformity  in  the 
previous  training  gives  unequalled  opportunity  for  legitimate 
comparison  between  different  persons.     Probably  no  other  form 


OCULAR   REACTIONS   IN   THE   PSYCHOSES  1 65 

of  reaction  is  common  to  so  many  different  persons  in  so  high  a 
state  of  development.  The  nearest  competitors  in  this  respect  are 
the  various  speech  functions ;  but  gross  differences  of  individual 
habits  and  training  render  generalization  concerning  the  latter 
more  difficult.  In  the  eye-movements,  on  the  other  hand,  we  may 
reasonably  assume  almost  complete  identity  of  practice  and  a 
general  high  grade  of  efficiency. 

Finally,  the  technique  of  recording  the  eye-movements  is  rela- 
tively simple.  By  using  the  corneal  reflection  as  the  registering 
medium,  there  is  absolutely  no  discomfort  to  the  patient  and  no 
unusual  stimulus  to  excite  him,  while  the  real  purport  of  the 
experiment  may  be  entirely  hidden  under  the  instructions  to  the 
patient  to  read  exposed  figures,  letters,  or  short  words,  or  simply 
to  try  if  he  can  see  anything  at  all  on  the  black  screen. 

On  the  other  hand,  the  photographic  procedure  is  not  without 
some  difficulties  of  its  own.  The  eyelid  may  droop  and  interfere 
with  the  recording  light  without  parallel  interference  with  vision. 
Excessive  head-movements  may  render  a  considerable  portion  of 
the  plate  illegible  or  take  the  patient  out  of  focus  of  the  record- 
ing camera.  But  the  records  themselves  are  their  own  vindica- 
tion, and  we  venture  to  believe  that  those  who  can  appreciate  the 
experimental  difficulties  of  securing  trustworthy  comparative  data 
will  find  some  satisfaction  in  our  results,  and  reasonable  ground 
for  expecting  more  of  the  general  procedure  in  the  future. 

The  most  serious  limitations  of  our  technique  arise  from  de- 
fective vision.  Just  how  far  this  may  finally  be  found  an  embar- 
rassment it  is  difficult  to  predict,  since  the  technique  permits  some 
use  of  correcting  glasses.  The  series  of  experiments  we  under- 
took was  planned  to  render  a  considerable  range  of  visual  defects 
indifferent ;  nevertheless,  in  three  cases  we  were  compelled  to 
abandon  the  tests  because  of  gross  refractive  errors. 

For  both  of  us  the  most  surprising  feature  of  the  experiment 
was  the  conduct  of  the  patients  during  the  tests.  We  anticipated 
a  considerable  variety  of  troubles,  particularly  from  the  maniacal 
patients,  and  safeguarded  the  apparatus  in  a  number  of  entirely 
unnecessary  ways.  Naturally  the  worst  cases  of  maniacal  excite- 
ment were  not  requisitioned ;  but,  as  will  later  appear  in  detail, 
we  succeeded  in  getting  excellent  records  from  patients  that  in 
the  wards  appeared  utterly  impossible. 


1 66  OCULAR   REACTIONS    IN    THE   PSYCHOSES 

In  only  two  cases  did  we  encounter  any  unwillingness  to  par- 
ticipate in  the  tests.  Something  about  the  experiments  seemed  to 
appeal  to  the  patients.  The  majority  were  helpful  in  getting  into 
position  and  maintaining  it.  Many  seemed  thoroughly  to  enjoy 
the  sessions ;  some  were  interested  in  the  results ;  some  were  more 
sensitive  than  others  to  the  blue  light,  as  was  evidenced  by  an 
occasional  increased  tendency  to  wink  or  to  withdraw  entirely 
from  the  apparatus,  but  the  light  was  stopped  down  by  blue  glass 
so  that  continuous  fixation  produced  only  a  mild  and  inoffensive 
after-image.    Many  of  the  patients  apparently  failed  to  notice  it. 

Apparatus  and  Technique 

The  registering  device  for  recording  the  eye-reactions  was  a 
modification  of  the  Dodge  photochronograph  which  was  designed 
by  one  of  the  authors,  and  has  been  used  by  him  practically  in  its 
present  form  during  the  last  five  years. 

As  used  by  us  it  consisted  of  an  enlarging  camera  of  fixed 
length  (about  5  ft.  [153  cm.])  fitted  with  a  Bausch  and  Lomb 
convertible  protar.  Series  VIIa.  The  device  for  producing  a  reg- 
ular motion  of  the  sensitive  photographic  plate  was  the  Dodge- 
Cline  falling  plate-holder.  It  consists  of  a  light-tight  box  2  ft. 
(61  cm.)  high  and  7  in.  (17.8  cm.)  wide,  fitted  with  opaque  slides, 
and  capable  of  quick  adjustment  to  the  rear  of  the  enlarging 
camera  like  a  regular  plate-holder.  Within  the  box  a  movable 
frame,  holding  a  5  in.  (12.7  cm.)  by  7  in.  (17.8  cm.)  photographic 
plate,  slides  vertically  on  two  brass  tracks,  so  adjusted  that  all 
lateral  play  is  taken  up  by  springs.  The  movement  of  the  sliding 
plate  frame  is  accurately  controlled  by  a  simple  hydrostatic  device. 
The  frame  is  attached  to  a  piston-rod  ending  in  a  plunger  which 
works  in  a  vertical  cylinder  of  lubricating  oil.  The  valve  of  the 
plunger  offers  no  resistance  as  the  latter  is  raised  through  the  oil, 
but  it  absolutely  resists  every  effort  to  force  it  downwards.  The 
release  of  the  plate  is  effected  by  opening  a  stop-cock  below  the 
plunger,  when  the  weight  of  the  plate-holder  forces  the  oil  out 
of  the  cylinder  at  the  bottom  through  the  stop-cock,  and  returns 
it  to  the  top  of  the  cylinder  above  the  plunger.  The  velocity  of 
the  fall  is  determined  by  the  opening  of  the  stop-cock,  the  vis- 
cosity of  the  oil,  and  the  weight  of  the  frame  and  plate. 


OCULAR    REACTIONS    IN    THE   PSYCHOSES  1 6/ 

The  photographic  record  is  made  on  the  falHng  plate  by  photo- 
graphing the  image  of  an  electric  arc  as  it  appears  at  the  cornea 
of  the  eye.  The  rays  of  the  arc  light  are  first  passed  through  blue 
glass  screens  to  eliminate  the  photographically  useless  but  physio- 
logically disturbing  rays  of  the  lower  spectrum.  Those  rays 
which  are  then  reflected  from  the  convex  surface  of  the  cornea 
to  the  camera  are  brought  to  a  focus  on  the  photographic  plate 
by  the  lens  of  the  enlarging  camera. 

A  convenient  and  well-nigh  necessary  modification  of  the  plate- 
holder  was  introduced  for  the  first  time  in  the  present  experi- 
ments. Since  one  cannot  presuppose  much  cooperation  on  the 
part  of  the  insane  in  finding  and  maintaining  the  proper  position 
of  the  head,  it  was  found  impossible  to  rely  on  methods  of  focus- 
ing that  were  satisfactory  for  normal  subjects.  A  focusing  and 
finding  glass  was  consequently  introduced  into  the  falling  plate- 
holder  just  below  the  photographic  plate,  and  in  the  same  plane. 
A  system  of  automatic  screens  was  arranged,  so  that  during  the 
focusing  process  the  plate  was  entirely  protected  from  light.  In 
this  way  we  could  quietly  await  the  opportune  moment  and  quickly 
adjust  the  apparatus  to  changes  in  the  patient's  position.  The 
apparent  movement  of  the  corneal  reflection  is  slightly  less  than 
half  the  actual  movement  of  the  eyes.- 

But  the  actual  displacement  is  magnified  by  the  enlarging 
camera  so  that  the  total  record  is  a  continuous  curve  whose  ampli- 
tude is  about  three  times  the  actual  amplitude  of  horizontal  eye- 
movements,  and  whose  height  is  determined  by  the  velocity  of  the 
plate.  Under  the  above  circumstances,  continuous  visual  fixation 
will  be  recorded  as  a  straight  vertical  line  on  the  falling  plate, 
while  any  horizontal  movement  of  the  eyes  will  be  indicated  by 
an  oblique  line  whose  obliquity  depends  on  the  relative  velocity 
of  the  horizontal  and  vertical  components. 

The  difference  in  illumination  between  the  corneal  reflection  of 
the  arc  light  and  its  background  is  sufficiently  marked,  so  that 
on  a  perfect  plate  there  is  no  trace  of  other  impressions  except 
the  record  made  by  the  corneal  image  of  the  arc  light.  This 
should  appear  as  a  fine  black  hair-line  on  an  almost  clear  back- 

^  For  the  mathematical  theory  of  the  movements  of  the  corneal  reflec- 
tion and  empirical  tests  of  its  accuracy  as  a  measure  of  eye-movements, 
see  Dodge,  Experimental  Study  of  Visual  Fixation  (8). 


l68  OCULAR   REACTIONS   IN    THE   PSYCHOSES 

ground.  No  limit  has  been  reached  in  the  number  of  records  one 
plate  will  hold,  except  the  purely  mechanical  confusion  of  the 
lines. 

In  our  experiments  the  stimulus  was  so  arranged  as  to  begin 
coincidently  with  the  beginning  of  the  record.  When  the  velocity 
of  the  plate  is  known,  the  duration  of  an  eye-reaction  will  be 
given  by  the  height  of  the  vertical  line  of  eye-fixation  between 
the  beginning  of  the  record  and  the  beginning  of  the  oblique  line 
of  eye-movement.  The  velocity  of  horizontal  eye-movement 
should  be  given  by  the  obliquity  of  the  line  of  eye-movement,  i.  e., 
the  time,  as  measured  by  the  fall  of  the  plate,  between  one  fixa- 
tion and  its  successor. 

Two  series  of  records  were  made.  One  depended  for  its  time- 
record  on  the  measured  length  and  obliquity  of  the  lines.  In  the 
other  an  interruption  of  the  recording  light  by  a  tuning-fork  gave 
the  time  directly  in  vibrations  of  the  tuning-fork.  Notwithstand- 
ing a  complex  system  of  controls,  our  first  records  of  the  angle- 
velocity  of  the  eyes  by  the  former  method  involved  such  serious 
sources  of  error  that  we  were  reluctantly  constrained  to  abandon 
them  as  practically  useless.  They  do  not  appear  in  this  report. 
The  reaction-records,  on  the  other  hand,  were  about  equally  satis- 
factory in  both  series.  Each  record  involves  a  probable  error  of 
less  than  o.oi  second. 

In  convenience  of  control  and  in  general  trustworthiness  the 
tuning-fork  interruption  of  the  recording  light  is  a  decided  ad- 
vantage.    It  was  arranged  as  follows : 

An  arc  light,  with  horizontal  upper  carbon,  was  mounted  on  a 
heavy  optical  bench  behind  a  large  condensing  lens.  In  front  of 
this  lens,  and  at  the  point  where  the  latter  brought  the  rays  of  the 
arc  light  to  a  focus,  was  placed  an  opaque  screen  with  an  opening 
which  was  so  shaped  and  oriented  that  at  each  vibration  of  an 
electric  tuning-fork  (a  tested  Koenig  tuning-fork  of  100.12  c.-p. 
per  second)  the  opening  was  alternately  opened  and  closed  to  the 
passage  of  the  light  from  the  arc.  A  second  smaller  lens  of  6  in. 
focus  was  so  placed  as  to  render  the  transmitted  rays  parallel. 
From  the  position  of  the  subject  one  isolated  vibration  of  the  fork 
exposed  the  arc  light  and  cut  it  off  again.  With  this  interrupted 
light,  when  the  tuning-fork  was  in  continuous  vibration,  each 
record  of  the  corneal  reflection  appeared  on  the  slowly  falling 


OCULAR   REACTIONS   IN    THE   PSYCHOSES  1 69 

photographic  plate  as  a  line  of  black  points  or  dashes.  From  the 
beginning  of  one  dash  to  the  beginning  of  the  next  represented 
a  time  interval  of  o.oi  second.  The  duration  of  any  fixation  or 
of  any  eye-movement  could  be  read  directly  from  the  appropriate 
record  in  units  of  O.oi  second  by  counting  the  corresponding  dots. 
The  arclight  and  the  tuning-fork  interrupter  were  placed  in  one 
corner  of  the  laboratory  at  a  distance  of  about  15  ft.  (459  cm.) 
from  the  patient.  The  patient  was  seated  comfortably  at  the 
apparatus  just  in  front  of  the  enlarging  camera.  His  head  was 
held  as  firmly  as  practicable  against  a  side-rest  and  a  nosepiece.^ 
Further  constraint  seemed  inadvisable.  The  resulting  records 
were  considerably  complicated  by  head-movements,  but  our  im- 
mediate interest  was  not  a  study  of  the  spatial  characteristics  of 
the  eye-movements,  but  rather  a  study  of  their  temporal  succes- 
sion. For  this  purpose  the  records  were  unequivocal,  except  in 
a  few  cases.  No  patient  was  in  the  apparatus  more  than  thirty 
minutes.  Under  favorable  circumstances  the  tests  occupied  about 
fifteen  minutes,  including  periods  of  relaxation.  All  records  are 
for  monocular  vision.  A  black  cardboard  screen  completely  hid 
the  unused  eye.  Three  groups  of  tests  were  made  on  each  patient 
at  each  sitting,  and  all  three  groups  were  recorded  on  the  same 

*  Figure  i,  a  half  tone,  could  not  be  inserted  here.  It  is  a  picture  of 
the  entire  apparatus  set  up  and  shows  on  the  left  the  subject  com- 
fortably seated  in  a  chair  with  the  arms  resting  on  the  table  and  the  head 
placed  against  a  side,  top  and  nose  rest.  About  one  foot  in  front  and  on 
a  level  with  the  eyes  there  is  a  single  photographic  lens  fitted  in  the  end 
of  an  enlarging  camera  box  five  feet  long  with  an  appropriate  standard 
and  terminating  in  the  box  of  the  falling  plate  holder,  all  resting  on  the 
same  long  table.  On  the  extreme  right  and  fifteen  feet  distance  from 
the  subject  on  another  table  is  the  light  apparatus  with  appropriate  hood, 
lenses  and  colored  glass  screen  to  produce  the  desired  rays,  so  thoroughly 
stopped  down  as  not  to  lighten  the  darkened  room  and  in  front  of  these 
the  black  screen  with  the  Koenig  tuning  fork,  resting  on  the  same  table. 
Partly  hidden  by  the  camera  box,  resting  on  the  same  table  with  it  one 
and  one  half  feet  in  front  and  a  little  to  the  left  of  the  patient  is  shown 
two  large  black  screens  with  openings  for  the  arc  recording  light.  These 
screens  are  as  nearly  as  possible  in  the  same  plane,  the  rear  one  being 
movable  and  carrying  the  test  objects  for  exposure  through  the  openings 
in  the  front  one.  Immediately  in  front  of  this  is  swung  the  pendulum, 
which,  when  not  in  use,  is  hitched  up  out  of  sight  of  the  subject. 


I/O  OCULAR   REACTIONS    IN    THE    PSYCHOSES 

plate.  In  this  way  each  plate  made  a  complete  experimental 
record  of  a  single  patient  at  the  time  of  examination.  The  plates 
were  carefully  numbered,  and  each  number  was  entered  in  a 
permanent  record  against  the  name  of  the  subject,  with  such  addi- 
tional notes  of  the  clinical  picture  and  conduct  of  the  patient  as 
seemed  pertinent. 

The  experiment  which  we  undertook  included  three  tests  for 
distinct  but  inter-related  phenomena. 

I.  Velocity  of  Eye-Movements 
(A)  Theory 

The  first  test  concerned  the  angle-velocity  of  simple  reactive 
eye-movement.  Experiments  on  normal  individuals  have  shown 
a  remarkable  uniformity  in  the  angle-velocity  of  similar  uninter- 
rupted eye-movements  of  the  same  person,  quite  independent  of 
direct  conscious  effort  to  move  the  eyes  fast  or  slowly.  There 
are  slight  variations  of  the  two  eyes,  and  slight  variations  in  suc- 
cessive movements,  but  under  similar  circumstances  these  varia- 
tions are  relatively  small.  The  first  published  records  of  the 
angle-velocity  of  the  eye-movements  noted  a  slight  but  clear  slow- 
ing up  of  a  rapid  succession  of  eye-movements  toward  the  end 
of  a  series  of  ten  movements.  This  was  tentatively  attributed  to 
fatigue.  A  series  of  records  taken  in  connection  with  a  hitherto 
unpublished  study  of  fatigue  confirmed  the  previous  findings  and 
justified  the  hypothesis  that  retardation  of  the  velocity  of  the 
eye-movements  is  a  phenomenon  of  fatigue. 

Valuable  as  they  undoubtedly  would  be,  it  was  hardly  to  be 
expected  that  adequate  fatigue  tests  could  be  obtained  from  the 
insane.  On  the  other  hand,  it  seemed  plausible  that  the  different 
disease  processes,  in  so  far  as  they  affected  the  psychomotor 
processes  at  all,  would  variously  affect  the  angle-velocity  of  the 
eye-movements.  It  also  seemed  probable  that  such  variations  in 
a  type  of  movement  which  is  equally  practised  for  all  subjects  and 
is  almost  entirely  removed  from  the  effects  of  voluntary  caprice, 
would  furnish  exceptionally  trustworthy  comparative  data. 

Naturally,  our  immediate  interest  centered  in  patients  suffering 
from  maniacal-depressive  insanity,  where,  as  a  matter  of  fact,  the 


OCULAR   REACTIONS    IN    THE   PSYCHOSES  I71 

most  marked  variations  from  normal  velocity  were  found,  but  the 
results  of  the  test  in  other  disease-processes  are  not  without 
interest. 

(B)   Experimental  Conditions 

The  test  for  the  angle-velocity  of  the  eye-movements  necessi- 
tated the  experimental  production  of  a  considerable  number  of 
rapid  reactive  eye-movements  of  the  first  type  (Dodge  [7])  of 
approximately  the  same  amplitude.  Taking  advantage  of  the 
fact  that  rapid  eye-movements  separate  the  fixation-pauses  (or 
moments  of  clear  vision)  in  reading,  we  satisfied  the  experimental 
requirement  by  exposing  a  succession  of  isolated  numerals  in  two 
dififerent  parts  of  the  field  of  regard  about  25°  apart.  The  read- 
ing of  one  numeral  by  the  patient  was  the  signal  for  the  operator 
to  cover  it  and  to  expose  another  25°  from  the  former.  When 
the  latter  was  read,  it  in  turn  disappeared  and  another  was  ex- 
posed where  the  first  had  been. 

The  eyes  rarely  moved  through  the  entire  25°  from  numeral  to 
numeral  in  a  single  rapid  eye-movement.  This  was  entirely  con- 
gruent with  the  known  facts  that  practically  every  long  eye- 
movement  involves  more  or  less  final  readjustment  in  the  form 
■of  short  corrective  movements.  When  the  object  of  interest  is 
relatively  obscure,  like  a  numeral  25°  from  the  fixation-point, 
the  normal  end-corrective  movements  will  vary  from  1°  to  5°. 
In  the  great  majority  of  cases  the  corrective  movement  is  in  the 
same  direction  as  the  initial  movement.  This  indicates  that  the 
initial  movement  was  too  short.  If  the  corrective  movement  was 
negative,  or  if  it  exceeded  one-sixth  of  the  total  displacement,  the 
record  was  discarded.  The  average  main  corrective  movements 
in  our  accepted  records  is  about  3°.  This  reduces  the  average 
displacement  corresponding  with  our  records  to  about  22°. 

A  large  black  screen  was  placed  at  i8  in.  (45.75  cm.)  in  front 
of  the  subject,  at  one  side  of  the  camera.  This  screen  was  per- 
manent and  served  all  three  experiments.  It  was  pierced  by  three 
openings  in  the  same  horizontal  line.  Two  openings  for  the 
exposure  of  objects  were  8  in.  (20.4  cm.)  apart.  The  middle 
opening  for  the  passage  of  the  blue  recording  light  was  5^  in.  (14 
cm.)  from  the  left  hand  opening  and  was  lost  in  the  blind  spot  of 


1/2  OCULAR   REACTIONS    IN    THE   PSYCHOSES 

the  right  eye  when  the  center  of  the  left  hand  opening  was  fixed. 
This  arrangement  with  respect  to  the  bHnd  spot  was  designed  to 
lessen  distraction  by  the  light  during  the  preliminary  focusing  of 
the  camera.  A  movable  black  cardboard  screen  behind  the  per- 
manent screen  carried  a  series  of  numerals.  These  were  so  ori- 
ented that  as  the  screen  fell,  step  by  step,  the  numbers  were  suc- 
cessively exposed  at  the  appropriate  openings  of  the  fixed  screen. 
The  movements  of  the  screen  were  regulated  by  the  operator. 
The  signal  to  the  operator  was  the  reading  of  the  exposed 
numerals  by  the  subject.  The  amplitude  of  each  movement  of  the 
screen  was  automatically  regulated  by  an  appropriate  escapement. 

Before  each  series  of  experiments  two  numbers  were  exposed 
respectively  in  the  left  and  right  hand  opening,  the  middle  one 
being  closed.  The  patient  was  told  that  other  numbers  would 
appear  in  the  same  places,  and  that  these  were  to  be  read  aloud 
as  rapidly  as  possible.  Foreigners  were  encouraged  to  use  the 
most  familiar  language.  With  the  initial  movement  of  the  screen 
the  middle  opening  was  uncovered,  allowing  the  subdued  arc  light 
to  illuminate  the  subject's  eye.  Four  groups  of  these  movement- 
records  were  taken  for  each  subject,  making,  when  all  the  lines 
were  legible,  twenty-four  movements.  This  number  was  unneces- 
sarily large,  since  the  mean  variation  is  regularly  less  than  half 
of  the  unit  of  measurement,  but  a  tendency  to  coordinate  winking 
just  at  the  time  of  eye-movements  together  with  head-movements 
and  interrupted  eye-movements  made  some  of  the  individual 
records  useless. 

Since  the  illumination  of  the  subject's  eye  was  the  condition  of 
a  photographic  record,  the  simultaneous  exposure  and  illumination 
were  a  mechanical  guarantee  that  the  beginning  of  the  photo- 
graphic record  was  synchronous  with  the  appearance  of  the  stimu- 
lus to  eye-movement.  This  arrangement  gave  the  chief  instru- 
mental condition  for  the  second  and  third  series  of  experiments  to 
determine  the  reaction-time  of  the  ocular  movements. 

(C)  Results 

Table  I  shows  the  average  duration  of  eye-movements  of  cr. 
22  for  nine  normals,  twenty-one  maniacal-depressives,  in  both  the 
maniacal  and  depressive  phases,  four  cases  of  dementia  praecox 


OCULAR   REACTIONS   IN    THE   PSYCHOSES 


173 


of  the  hebephrenic  type,   four  epileptics,   six  paretics  and  one 
imbecile. 

Under  each  form  of  insanity  the  data  are  arranged  according  to 
the  severity  of  the  disease.  The  most  marked  cases  come  first. 
Each  case  is  described  at  length  under  the  corresponding  number 
in  the  Appendix.     All  time-values  are  given  in  M.000  second. 


I 
2 
3 
4 


9 
10 


Normal 

.  R.  D.  . 

.  A 

.  Wh.   ., 

.  Wr.    .. 


Female  Nurses 

LI 

E.  F 


Male  Nurses 

11   W.  S.  ... 

12  J.  R.    ... 


59 
59 
61 
60 


60 
54 


62 
60 


13 
14 
15 
18 

19 
Average 


TABLE    I 

Mania' 

Marked 

.  S.  S 

.  J.  c 

.  W.  B.  .. 
.  T  S.  ... 
.  J.  G.    ... 


Depression' 
Marked 

59  26  ....  H.  N.  (a-c)  55 

44     32  ....   P.  F.  (a)  ..  74 

60  29 R.  R yy 

51     Average    69 

55 

54  Less  Marked 

33  K;  B 72 


Less  Marked 

31   ...  L.  K.  (b)   . 

21   ...  A.  H 

27  ...  M.  G.  (c-d) 

33  ...  KB.  (b)  . 


60 

56  34  •• 

47  High 

59  Low 


Recovered  Patient         Average    55 


17 M.  D.  (c) 

Average    

Low  

High    

M.  V 


60 
59 
54 
62 

1-5 


Hypomania 

22  ...    G 50 

29  ...  R.  R.  (a)   . .  65 

23  ...  A.  T 76 

20  . . .   S.  K.  (c)   . .  51 

24  ...   P.  B 61 

25  ...  P.  R 70 

Average  62 

Low    44,  marked 

High   76,  hypo 


Slight 

T  B SI 

. . .  77 — marked 
...  51— slight 


Dementia  Precox         Dementia   Paralytica 


36 
37 


Marked 
.  A.  R.  . 
.  M.  B.  . 


Moderate 

40  G.  L.  . . 

41   M.F.  . 


62 

52 

60 

50 


Marked 

43  D.D. 

44 W.  H. 

45 A.  B. 

47  A.  S.  . 

Average   


54 
53 
60 
60 

57 


51 
52 


Epileptic 

Moderate 
..  G.  L.   .. 
. .  J.  F.   . . 


53  H.O. 

54  •• 


M.  B. 


Average 


'  Maniacal  phase  of  manic-depressive  insanity. 
*  Depressed  phase  of  manic-depressive  insanity. 


67 
64 
67 
80 
69 


1/4  OCULAR   REACTIONS    IN    THE   PSYCHOSES 

Less  Marked 

Slight  48  J.  P.  E.  .. .  54  Imbecile 

42  B.  M 56     49 J.  A 49     57  R.  H 60 

Average    56     Average    51 

From  the  preceding  table  (I)  it  is  obvious  that  the  velocity  of 
the  eye-movements  of  manic-depressive  patients  does  not  vary 
exactly  with  the  degree  of  depression  or  of  maniacal  excitement 
which  they  present.  On  the  other  hand,  it  should  be  noted  that 
there  is  some  variation  even  among  normal  persons.  In  any  fair 
evaluation  of  our  data,  then,  one  must  allow  at  the  outset  for 
some  individual  variations,  independent  of  all  disease.  The  origin 
of  these  individual  variations  is  at  present  a  matter  of  conjecture. 
Earlier  studies  (6,  9)  demonstrated  that  the  differences  between 
individuals  are  not  absolutely  constant  for  different  angles  of 
movement,  or  for  the  same  angle  of  movement  at  different  times. 
But  these  variations  are  relatively  small,  and  are  due,  in  part  at 
least,  to  minor  variations  in  the  action  of  opposed  and  cooperating 
muscles  which  are  not  further  analysed,  and  which  may  be 
grouped  together  for  our  purposes  as  chance  variations.  But 
after  due  allowance  is  made  for  these  chance  variations,  the 
grossness  of  the  variations  in  the  insane  and  certain  very  obvious 
tendencies  in  different  diseases  and  in  different  phases  of  the  same 
disease  indicate  some  causal  interdependence  with  the  disease 
itself. 

While  it  would  be  injudicious  to  regard  these  tendencies  as 
settled  before  our  data  have  been  materially  increased,  the  marked 
variations  of  the  extreme  maniacal  and  the  extreme  depressive 
states  may  safely  be  regarded  as  characteristic.  This  appears  not 
merely  from  Table  I,  but  still  more  convincingly  from  the  his- 
tory of  such  cases  as  26,  H.  N.,  p.  173 ;  29,  R.  R.,  p.  173 ;  and  33, 
K.  B.,  p.  173.  So  again  both  patients  suffering  from  dementia 
praecox  and  dementia  paralytica  have  abnormally  rapid  eye-move- 
ments, while  the  epileptics  are  notably  long.  The  slow  eye-move- 
ments of  the  extreme  depressive  and  the  quick  eye-movements  of 
the  extreme  maniacal  coincide  with  the  general  phycho-motor  dis- 
turbances as  they  appear  in  the  familiar  clinical  picture  of  these 
psychoses.      Quantitative    evidence    of    abnormal    quickness    of 


OCULAR   REACTIONS   IN    THE   PSYCHOSES 


175 


maniacal  movements  has,  however,  hitherto  been  conspicuously 
lacking.      On   the   other   hand,   it   is   again   congruent   with   the 


Normal    Is 


j. 


':~:::i 


Depressed  29.2 


■v«* 


r^ 


/ 


Paretic  44 
Plate  I 


] 


Praccox  40 


Plate  I  is  a  reproduction  of  typical  records  of  eye-movements.  The 
records  were  projected  by  lantern  and  drawn  from  the  projected  image  on  a 
much  enlarged  scale.  These  drawings  are  here  reprouced  by  process  on  a 
somewhat  reduced  scale.  The  resulting  lines  reproduce  the  original  records 
very  well,  save  that  the  dashes  are  relatively  fainter  grey  in  the  records. 
The  exact  shape  of  each  dash  is  not  accurately  reproduced.  In  all  cases 
which  are  represented  in  Plate  I  the  photographic  plate  was  moving  so 
slowly  that  the  dots  run  together  in  the  vertical  lines,  appearing  as  dashes 
only  during  eye-movement.  The  dashes  represent  flashes  of  light  succeed- 
ing each  other  every  o.oi  second.  The  paretic  line,  No.  44.1,  is  an  extreme 
case  of  head-movement  and  broken  lines.  The  broken  movements  are 
typical,  the  head-movements  less  so. 


1/6  OCULAR   REACTIONS    IN    THE   PSYCHOSES 

disease-picture  that  the  eye-movements,  which  we  have  found  to 
be  rapid,  are  secondary  automatic  acts,  not  those  that  require 
conscious  direction  and  control  such  as  have  hitherto  been  meas- 
ured ;  and  it  certainly  corresponds  closely  with  our  general  knowl- 
edge of  the  diffusion  of  the  sensory  impulses  and  the  interaction 
of  the  higher  and  lower  nervous  centers,  that  these  secondary 
automatic  movements  should  reach  their  extreme  velocity  when 
the  interaction  of  the  higher  nervous  centers  is  lessened. 

The  slowness  of  the  eye-movements  in  the  depressives  and  in 
the  epileptics  cannot  be  accounted  for  conversely  by  excessive 
interference  of  the  higher  centers.  It  seems  rather  to  be  the  ex- 
pression of  a  more  widespread  involvement  resulting  in  a  gen- 
eral inefficiency  of  the  whole  psychomotor  system  and  including 
not  only  the  higher  centers,  which  appeared  to  be  chiefly  involved 
in  mania,  but  also  the  lower  centers,  the  simple  reflexes,  and  the 
automatic  acts. 

Besides  the  mere  differences  of  velocity  in  the  eye-movements, 
there  are  certain  characteristic  tendencies  in  form  and  accuracy  of 
eye-movement  that  our  technique  was  not  designed  to  measure, 
but  which  may  be  mentioned  in  passing.  Along  with  the  increased 
velocity  in  the  maniacal  eye-movements,  there  is  a  parallel  tend- 
ency to  abnormal  overshoots  such  as  were  first  described  in  nor- 
mal persons  by  E.  B.  Huey  (3).  Depressive  eye-movements  are 
more  regular  and  symmetrical.  The  eye  slides  up  into  the  new 
position  as  though  against  a  gradually  increasing  resistance. 

The  eye-movements  of  the  grossly  demented  show  marked  inac- 
curacies of  fixation.  Advanced  dementia  paralytica  has  curious 
inconsequential  fixations,  breaking  the  normal  eye-movements  at 
irregular  points. 

2.  Ocular  Reaction-Time  to  New  Peripheral  Stimuli 

The  second  test  concerned  the  simple  reaction  of  the  eye  in 
responding  to  a  peripheral  stimulus.  Like  the  first  test,  the  sec- 
ond also  depended  on  the  regular  and  usually  wholly  unconscious 
habit  of  fixing  a  numeral  or  letter  one  is  expected  to  read. 

(A)  Experimental  Conditions 

The  procedure  was  as  follows :  A  figure  6  was  exposed  in  the 
left  hand  slit  of  the  permanent  screen.     The  subject's  attention 


OCULAR   REACTIONS   IN    THE   PSYCHOSES  1 77 

was  directed  to  it  with  the  instructions  that  other  figures,  which 
would  appear  at  one  side  or  other  of  the  6,  must  be  read  as  rapidly 
as  possible.  With  the  final  warning  to  look  sharp,  the  6  suddenly 
dropped  out  of  sight  and  i  in.  (2.5  cm.)  to  the  right  or  left  there 
appeared  a  different  numeral.  The  exposure  apparatus  resembled 
that  used  in  the  first  series  of  experiments.  A  special  exposure 
screen  was  prepared  so  as  to  expose  one  figure  (6)  at  the  center 
of  the  left  hand  opening  in  the  permanent  screen  when  the  ex- 
posure screen  occupied  its  primary  position.  A  series  of  numbers 
was  pasted  on  pieces  of  black  cardboard  which  could  be  slipped 
into  place  either  to  the  right  or  left  of  the  6  and  just  so  far  above 
it  as  would  bring  them  into  view  by  one  stroke  of  the  escapement. 
It  only  required  ^  in.  (1.25  cm.)  movement  of  the  exposure  screen 
to  carry  the  6  out  of  sight  and  to  expose  the  new  number.  The 
movement  was  so  rapid  that  it  seemed  like  an  instantaneous 
change.  Without  the  appearance  of  motion  in  any  direction,  the 
one  seemed  to  disappear  and  the  other  was  in  place.  The  same 
movement  of  the  exposure  screen  uncovered  the  arc  light  and 
began  the  photographic  record.  Simply  counting  the  dashes  of 
which  the  record  was  composed  from  the  beginning  of  the  record 
to  the  beginning  of  the  eye-movements  to  fix  the  new  number 
gave  the  reaction  time  of  the  eye  in  o.oi  second.  A  similar  ex- 
periment is  described  more  in  detail  in  Dodge's  "  Experimental 
Study  of  Visual  Fixation  "  (8).  Vocal  reaction  to  printed  matter 
or  to  isolated  words,  such  as  Dodge  studied,  seemed  inexpedient 
in  these  tests  on  account  of  gross  differences  in  education.  Four 
ocular  reactions  were  taken  for  each  subject.  Unfortunately,  in 
some  cases  extreme  head-movements  made  some  of  the  records 
uncertain,  while  winking  made  other  records  useless.  These  two 
disturbances  combined  materially  to  reduce  the  number  of  avail- 
able records. 

The  small  number  of  reactions  for  any  one  individual  is  a 
serious  limitation  to  the  use  of  our  data.  If  we  had  the  work  to 
do  over  again,  we  are  agreed  that  we  should  venture  to  increase 
the  number  of  simple  reactions.  Our  reason  for  limiting  the 
number  in  the  present  tests  was  the  consciousness  that  we  were 
dealing  with  subjects  who  were  abnormally  susceptible  to  fatigue 
of  attention.     To  some  of  them  even   four  tests  of  the  same 

13 


1/8 


OCULAR   REACTIONS    IN    THE   PSYCHOSES 


kind  seemed  many.  For  the  sake  of  comparison,  we  ran  through 
a  series  of  ten  reactions  each  with  two  more  tractable  cases.  The 
results  show  that,  in  these  two  cases  at  least,  the  smaller  number 
did  no  violence  to  the  facts.  In  later  discussions  it  will  appear 
that  minimal  reactions  and  the  general  variability  are  quite  as 
important  as  the  rather  meaningless  averages. 


(B)  Results 

TABLE   II 

Simple  Ocular  Reactions  to  Periphekal  Stimuli 


I 

2 

3 
4 


I.  Normal 

.  R.D.    ... 

.  A 

.  Wh 

.  Wr 


200 
20O 

215 
210 


Average 206 


5 
6 

7 
8 

9 
10 


H.  . 
T.  . 
Wi. 
C.  .. 
LI.  . 
E.F. 


192 
249 
140 

247 
223 

195 


Average    208 

11  ...  W.S 198 

12  ...  J.  R 225 

Average    211 


2.  Mania 

Marked 

13  ••••   S.    S 205 

14 J.    C 210 

217 

16 M.   M 225 

17  M.  D.  (a) . .  250 

18  ..'. .  T.   S 250 

19 J.   G 210 

20 S.  K.  (&) ..  229 

Average  224 

Less  Marked 

31   L.  K.  (c) ..  260 

21  A.  H 215 

27  . . . .  M.  G.  (d) . .  257 

22,  ....  KB.  (&)..  219 

Average  238 


3.  Depression 

Marked 

26  ...  H.N.  (o)  250 

27  ...  M.  G.  ...  295 
29  ...  R.R.   (c).  173 

Less  Marked 
32  ...  P.  F.    ...  379 

Slight 

34  •  •  •   T.  B 293 

17  ...  M.  D.  (6)  204 

Average   266 

High 379 

Low 173 


17  ...   M. D.    ...  222 
Average  222 

Average  209 

High  249 

Low    140 


Hypomania 


22  . . 

..  G.  ... 

.  230 

23  •• 

..  P.  A. 

.  225 

20  .. 

..  S.  K. 

(c). 

.  202 

24  .. 

..  P.  B. 

.... 

.  170 

25  •• 

..  P.  R. 

.... 

.  230 

Average 


211 


Average   224 

High 260 

Low  Hypo   170 


OCULAR   REACTIONS    IN    THE   PSYCHOSES 


179 


4.  Dementia  Precox 
Marked 

36  ...  A.  R 240 

37  ■■•  M.  B 185 

38  ...  R.B 258 

Average  228 

Moderate 

39  ...  A.  McI.  ..  276 

41  ...  M.  F.  ...  220 

Slight 

42  ...  B.  M.  ...   152 

Average  222 

High     276 

Low    152 


5.  Dementia  Par 

alytica 

6.  Epileptic 

Marked 

Moderate 

43  ....  D.  D.   . 

...  370 

51 

...  G.  L.   ... 

298 

44  ....  W.  H. 

...  237 

52 

...  J.    F.    ... 

228 

45  ....  A.  B.   . 

...  225 

53 

. . .  H.  0.   . . . 

195 

47  ....  A.  S.    . 

...  237 

54 

. . .  M.  B.  . . . 

197 

Average    

...  267 

Less  Marked 

48 J.  P.  E.  ...  190  Average 

49  ....  J.   A 217  High  ... 

Average 203  Low    . . . 


(50 


Remission 
.  F.  A.   . . . 


Average 
High  . . . 
Low    . . . 


193) 

.  246 
-  370 
.   190 


229 
298 
195 


(C)  Discussion  of  Table  II 

The  simple  ocular  reaction-time  is  long.  According  to  our 
records  the  normal  average  lies  above  2000-.  In  strict  accuracy 
this  average  is  undoubtedly  too  high,  and  should  be  reduced  by  a 
constant  instrumental  error  of  about  fifteen.  This  error  is  in- 
volved in  the  form  of  the  exposure  of  the  peripheral  stimulus. 
We  have  not  tried  to  correct  it,  since  it  applies  equally  for  all 
subjects,  and  our  interest  lies  mainly  in  comparative  rather  than 
absolute  time  estimations.  But  after  all  corrections  are  made, 
these  records  agree  w^ith  all  the  available  data,  and  the  simple 
ocular  reaction-time  is  long. 

One  might  a  priori  have  expected  that  a  reaction  which  is  at 
once  so  common  and  apparently  so  necessary  to  the  welfare  of 
the  individual  in  the  conduct  of  life  would  be  short.  On  the  other 
hand,  it  must  be  noted  that  each  ocular  reaction  to  peripheral 
stimuli  involves  a  considerable  sensori-motor  elaboration  of  the 
stimulus.  The  adequate  reacting  eye-movement  is  not  only  in  a 
definite  direction,  but  it  is  also  of  definite  extent.  The  accuracy 
of  the  eye-movement  does  not  now  concern  us,  since  we  measure 
in  reaction-time  only  the  beginning  of  the  reactive  movement. 
But  the  beginning  of  every  eye-movement  is  really  only  the  initial 
phase  of  a  movement  of  definite  direction  and  extent.     Before 


l8o  OCULAR   REACTIONS    IN    THE    PSYCHOSES 

the  eye  starts,  the  elaboration  of  that  particular  motor  impulse 
must  be  relatively  complete.  An  accurate  account  of  the  cor- 
respondence between  reaction-time  and  reaction-accuracy  is  a 
desideratum. 

In  a  sense,  every  ocular  reaction  to  a  peripheral  stimulus  is  not 
a  simple  reaction  at  all,  but  an  individual  adaptation  to  a  change 
in  the  environment.  In  the  past,  such  a  reaction  would  have 
borne  the  misleading  name  of  a  "  choice  reaction."  The  length 
of  the  simple  ocular  reaction,  then,  is  not  an  anomaly.  It  corre- 
sponds directly  with  the  complex  but  automatic  elaboration  of  the 
sensori-motor  impulse. 

Abnormal  reactions  may  result  from  an  indefinite  number  of 
changes  within  this  complex  sensori-motor  process.  This  is  at 
once  the  inspiration  and  the  danger  of  every  interpretation  of 
complex  reactions.  In  view  of  the  possible  complications,  the 
relatively  small  mean  variation  for  normal  subjects  points  to  a 
relatively  stable  normal  oculo-motor  systematization.  It  em- 
phasizes at  the  same  time  the  gross  variations  of  the  insane. 

The  small  number  of  per  capita  records  forces  us  to  consider 
the  reactions,  as  we  were  led  to  consider  the  velocity  of  movement 
by  groups  rather  than  by  individuals.  Furthermore,  we  will 
again  limit  our  generalizations  to  such  gross  variations  as  are 
inexplicable  on  the  basis  of  chance  variations. 

The  most  conspicuous  comparative  feature  of  the  results  is  the 
abnormally  long  reactions  of  the  maniacal-depressive  patients. 
Not  only  do  they  average  long,  but,  with  one  exception,  the  aver- 
age reactions  of  both  the  extreme  and  the  less  marked  maniacal, 
and  of  all  the  depressed  with  one  exception,  are  above  the  normal. 
These  data  are  not  novel.  They  agree  with  the  reaction  experi- 
ments of  Franz. 

In  view  of  the  unequivocal  testimony  of  the  averages,  it  is 
somewhat  disappointing  to  note  that  there  is  no  direct  corre- 
spondence between  the  duration  of  the  ocular  reactions  and  the 
clinical  judgment  of  the  severity  of  the  disease.  It  is  hardly  an 
accident  that  in  spite  of  the  high  averages  in  cases  of  mania  the 
most  extreme  maniacal  excitement  had  the  shortest  ocular  reac- 
tion; while  the  maniacal  group,  which  averages  the  longest,  is 
that  of  the  less  marked  excitement.  In  view  of  the  complica- 
tion of  the  reaction-process  and  the  number  of  unanalyzed  factors. 


OCULAR   REACTIONS    IN    THE   PSYCHOSES  l8l 

we  feel  that  any  hypothesis  of  the  effect  of  the  disease  on  the 
reaction  must  be  regarded  as  tentative.  But  on  grounds  which 
will  appear  most  clearly  in  the  discussion  of  the  pursuit-reactions, 
we  believe  that  the  inconsequential  reactions  of  maniacal  excite- 
ment are  due  to  opposed  tendencies  in  the  inter-relation  of  the 
superior  and  the  secondary  central  systematizations. 

3.  Ocular  Pursuit-Reactions 
(A)   Theory 

The  third  series  of  tests  was  a  reaction  experiment  of  unusual 
character.  The  simplest  and,  in  the  end,  also  the  most  complex 
ocular  reaction  with  which  we  are  acquainted  is  the  pursuit- 
movement  in  reaction  to  moving  pendulum. 

It  is  the  simplest,  in  the  sense  that  no  new  object  of  regard  is 
furnished  as  stimulus  for  reaction.  There  is  no  change  in  the 
object  of  attention.  An  object  is  fixed,  and  the  fixation  lapses 
through  the  movement  of  the  object  fixed.  The  reestablishment 
of  the  lapsed  fixation  involves  a  form  of  ocular  reaction  such  as 
occurs  on  an  average  several  times  a  minute  throughout  the  wak- 
ing day,  either  because  the  object  moves  or  because  of  involun- 
tary displacement  of  the  eyes  by  bodily  movements.  Pursuit- 
reactions,  as  we  may  call  them,  normally  involve  a  reaction- 
time  slightly  longer  than  the  simple  reactions  to  peripheral  stimuli. 
At  least  one  factor  tending  to  lengthen  the  pursuit-reaction  appears 
directly  in  the  form  of  the  stimulus.  The  stim.ulus  to  reaction  is 
not  given  in  the  release  of  the  pendulum,  but  only  when,  after 
release,  the  pendulum  has  moved  some  appreciable  distance. 
The  amount  of  movement  that  will  constitute  a  stimulus  to  pur- 
suit will  depend  on  the  training  of  the  subject  and  the  accuracy 
with  which  he  maintains  his  fixations. 

Paradoxical  as  it  might  at  first  seem,  the  total  pursuit-reaction 
finally  involves  more  extensive  psychomotor  elaboration  than  any 
other  ocular  reaction  that  we  know  how  to  produce.  As  is  now 
well  known  (Dodge  [7]),  the  true  pursuit  eye-movements  are 
totally  different  in  function  and  character  from  the  rapid  reaction- 
movements  of  the  eyes  by  which  peripheral  objects  of  interest 
are  fixated.  The  rapid  movements  are  relatively  constant  in 
duration,   and   they   constitute   moments   of  practical   blindness. 


1 82  OCULAR   REACTIONS    IN    THE    PSYCHOSES 

The  reason  for  this  eye-movement  bHndness  is  still  under  discus- 
sion. There  is  no  debate  concerning  the  fact.  The  pursuit- 
movements,  on  the  other  hand,  vary  in  angle-velocity  with  the 
angle- velocity  of  the  moving  object.  The  eyes  move  fast  or 
slowly  as  the  object  moves  fast  or  slowly.  Moreover,  the  pur- 
suit-movements are  pre-eminently  moments  of  relatively  clear 
vision.  It  is  because  we  wish  to  see  an  object  clearly  that  we 
move  the  eyes  as  the  object  moves  and  keep  its  image  on  retinal 
areas  of  relatively  clear  vision.  Furthermore,  the  psychomotor 
elaboration  of  the  simple  ocular  reaction  is  fixed  by  the  long- 
established  habit  of  bringing  excitations  of  the  peripheral  retina  to 
areas  of  clear  vision.  The  psychomotor  elaboration  of  the  pur- 
suit-movements, on  the  other  hand,  is  in  practically  each  instance 
of  pursuit  an  unique  psychomotor  problem.  The  reaction  to 
pursuit  is  fixed  and  habitual  enough,  but  the  velocity  of  the  eye 
which  shall  correspond  to  the  velocity  of  the  object  at  the  distance 
it  chances  to  be  can  scarcely  ever  be  a  motor  habit.  To  be  a  suc- 
cessful pursuit  there  must  be  an  adaptation  of  the  general  pursuit 
tendency  to  the  peculiar  condition  of  each  separate  instance. 
Especially  in  the  pendulum  pursuit-movements  are  these  condi- 
tions so  various  as  to  present,  in  each  new  case,  practically  unique 
conditions.  Angle-velocity,  apparent  amplitude,  and  period  of 
oscillation  would  all  be  alike  only  if  pendulums  of  the  same  length 
swing  through  the  same  arc  at  the  same  distance  from  the  eye  of 
the  observer.  Yet  unique  as  each  case  actually  is,  a  normal  eye 
will  fall  into  an  adequate  pendulum  pursuit-movement  with  sur- 
prising quickness  and  accuracy.  In  every  normal  individual  the 
very  first  fixation  after  the  initial  reaction  to  a  moving  pendulum 
has  the  characteristic  true  pursuit-slide,  even  though  it  usually 
corresponds  in  angle-velocity  to  the  first  part  of  the  pendulum 
swing,  and  is  consequently  too  slow.  Let  us  emphasize  the  fact : 
for  normal  individuals,  however  inadequate  the  first  attempt  to 
fix  the  moving  object  may  be,  it  always  has  the  characteristics  of 
a  true  pursuit-movement  (see  Plate,  lines  i,  lo,  ii). 

The  return  swing  of  a  second  pendulum  is  usually  followed 
with  precision,  except  at  or  near  the  middle  of  the  arc  of  oscilla- 
tion, when  one  or  two  short,  sharp,  rapid  movements  break  the 
simple  pendulum  pursuits.  The  character  of  these  pendulum 
pursuits  scarcely  alters,  even  after  a  large  number  of  experiments 


OCULAR   REACTIONS   IN    THE   PSYCHOSES  1 83 

under  the  same  objective  condition.  Each  new  pursuit  seems  to 
be  solved  de  novo,  and  the  short-lived  motor  habits  involved  in 
every  adequate  pursuit  seem  to  be  lost  when  the  pursuit  is  inter- 
rupted (8). 

This  ability  to  elaborate  adequate  pursuit-movements,  i.  e.,  to 
adopt  an  adequate  motor  response  to  the  peculiar  situation  pres- 
ented by  the  rhythmic  movements  of  an  object,  varies  widely  in 
mental  disease.  In  some  respects,  the  most  marked  variations  are 
found  in  the  pendulum  pursuit-movements  in  dementia  praecox, 
where  a  marked  hesitation  to  fall  into  the  swing  of  the  pendulum 
was  found  even  in  the  mildest  cases.  While  this  peculiarity  is  ap- 
parently not  absolutely  restricted  to  dementia  praecox,  it  was 
found  in  other  patients  only  where  the  disease-process  has  pro- 
duced marked  deterioration. 

(B)  Experimental  Conditions 

The  instrumental  device  for  producing  the  pursuit-reaction  and 
the  subsequent  pursuit-movements  was  a  number  attached  to  the 
bob  of  a  second  pendulum.  The  latter  hung  just  in  front  of  the 
fixed  screen  with  its  axis  vertically  above  the  middle  point 
between  the  extreme  left  and  right  hand  opening.  Before  the 
experiment  the  pendulum  was  held  out  of  equilibrium  in  front 
of  the  left  hand  opening  by  a  simple  catch  attached  to  a  falling 
screen  in  the  usual  place  behind  the  fixed  screen.  This  falling 
screen  was  released  by  the  operator,  as  in  the  other  experiments, 
and  the  release  of  the  screen  simultaneously  started  the  pendu- 
lum and  opened  the  way  for  the  recording  beam  of  light.  In 
every  case  the  patient  was  previously  shown  how  the  pendulum 
moved  and  was  then  requested  to  watch  the  number  closely,  to 
keep  his  eyes  on  it,  not  to  lose  it,  watch  it,  &c. 


1 84 


OCULAR   REACTIONS   IN    THE   PSYCHOSES 


Ocular 
I.  Normal 


(C)  Results 
TABLE  III 

Reactions  in  Pursuit  of  a 
2.  Mania 


Moving  Stimulus 

3.  Depression 


1  ...  R.D. 

2  ...  A.    . 

3  ...  Wh. 

4  ...  Wr. 
Average  . . . 


5 
6 

7 
8 

9 
10 


H.  .. 
T.  ., 
Wi.  . 
C.  ., 
LI.  ., 
E.F. 


Average 


11  ...  W.S. 

12  ...  J.  R. 
Average  . . . . 


17 


M.  D. 


Average 
High  . . . 
Low    . . . 


198 
233 
243 
210 
221 

274 
284 
216 
225 
26s 
285 
258 

235 
223 
229 

223 

239 
285 
198 


13 
14 


Marked 
S.  S.  ... 
J.C.  ... 


M.  M. 
T.S.  . 
J.G.  . 
S.K.  . 


16  . 

18  . 

19  . 

20  . 
Average 

Less  Marked 
31  ....  L.K.  (c)  .. 

21  ....  A.  H 

27  ....  M.  G.  (c-d) 
33  ....  K.B.  (&)  .. 
Average  

Hypomania 

.  G 

.  R.  R.  (a)  . . 

.  P.  A 

.  S.K.  (c)  .. 

.  P.  B 

.  P.R 


22 
29 

23 
20 

24 

25 

Average 

Average  

High  (marked) 
Low  (Hypo)  . . . 


190 
225 
222 

343 
217 

225 

314 
248 

260 
217 
305 

255 
259 

210 
220 
240 
212 
155 
273 
218 

240 

343 
155 


4.  Dementia  Precox       5.  Dementia  Paralytica 


36  . 

37  ■ 

39  ■ 

40  . 

41  . 


Marked 
.  A.R.  ... 
.  M.  B.  . . . 

Moderate 
.  A.  McL  . 
.  G.L.  ... 
.  M.  F.  . . . 


Slight 
42  ...  B.  M.  . 

Average 

High    

Low    


30s 
195 

207 
260 

215 

275 
243 
305 
195 


Marked 

43  ..••  D.D 

44  •  ■ . .  W.  H 

45  ■•..  A.B 

47  ....  A.  S 

Less  Marked 

48  ....  J.  P.  E 

Average 

High 

Low    

Average  excluding 
high    


445 
240 
224 
267 

227 

281 

445 
224 

239 


Marked 

27  ...  M.  G 379 

28  ...   M.  C 255 

29  ...  R.  R.  (c).  230 

30  . . .  L.  W.    ...  339 


Average 


301 


Less  Marked 
Slight 

34  ...  T.  B 303 

17  ...  M.  D.  (b)  272 
Average 287 


Average 
High    ... 
Low    . . . 


296 

379 
230 


6.  Epileptic 

Moderate 

..  G.L.   . 

..  J.F.  .. 

. .  H.  O.  , 

. .  M.  B.  . 


51 
52 
53 
54 
Average 


280 
222 
230 
221 
238 


OCULAR    REACTIONS    IN    THE   PSYCHOSES  1 85 

TABLE   IV 
Table  of  Comparison  of  Avekages 
Normal  Depression  Dementia  Paralytica 

Mvt.     Reactions   Pu^^"''-  Marked  Marked 

reactions  t>         ■  p         • 

59   ....    209    ....   239  Mvt.  Reactioss      P^";=;j,'^;         Mxt.         Reactions  P™^", 

69 239 301  57  •■ .  •  267  ....  294 

Mania 

Marked  Less  Marked  and  Slight  Total 

54 224 248  61   295  287  55   246  ....  281 

Less  Marked  Dementia  Precox  Epileptic 

55 238 259         Moderate,    Marked    and        69  ....  229  —  238 

Slight 

Hypomania  56 222  243 

62  211  ....  218 


(D)  Discussion  of  Table  III 

In  all  classes  except  in  moderate  depression  the  pursuit-move- 
ment reaction  averages  longer  than  the  simple  ocular  reaction. 
The  differences  between  the  two,  however,  are  not  constant.  Even 
in  the  group  of  normal  persons  the  differences  are  not  constant. 
The  variations,  however,  allow  of  some  degree  of  classification. 
It  must  be  remembered  that  the  stimulus  to  pursuit-movement  is 
not  mechanically  fixed  as  was  the  stimulus  to  a  new  peripheral 
stimulus.  The  movements  of  the  pendulum  operate  as  a  stimulus 
to  pursuit  only  when  the  lapsed  fixation  in  some  way  makes  itself 
felt  through  the  indistinctness  of  the  object.  For  the  trained 
observer  it  operates  almost  immediately.  For  the  less  trained 
it  operates  only  after  the  pendulum  has  moved  some  clearly  ap- 
preciable distance.  The  mean  difference  between  pendulum-  and 
pursuit-reactions  for  normal  observers  under  the  conditions  of 
our  test  was  approximately  300-.  This  average  difference  holds 
approximately  the  same  for  praecox  and  for  the  longer  reactions 
of  paresis.  It  does  not  hold  for  maniacal-depressives.  But  the 
individual  variations  are  so  great  that  the  maniacal-depressive  dif- 
ferences can  scarcely  be  spoken  of  as  characteristic.  It  does, 
however,  constitute  additional  evidence  of  a  high  degree  of  dis- 
turbance of  those  complex  superior  central  processes  which  are 
usually  grouped  under  the  general  name  of  attention.  Further 
evidence  to  the  same  effect  comes  from  a  consideration  of  minimal 
reactions,  which  are  given  in  Table  V. 


i86 


OCULAR   REACTIONS    IN    THE   PSYCHOSES 


I 
2 
3 
4 
5 
6 

7 
8 

9 

10 

II 

12 

17 


Normal 
,.  i8o  ... 
. .  i8o  ... 
, .  2o6  . . . 

.  .  200  . . . 

,.  i66  ... 


230 
128 

243 
200 
180 
140 
210 
220 


180 
200 
230 
200 
260 
273 
179 
179 
240 
260 
200 

2X0 
190 


Average  191  216 


Dementia  Precox 


TABLE  V 
Table  of  Minimal  Reactions 
Mania 
Mania 

13  180 180 

14  180  180 

16 186  257 

17  205 

18  210  200 

19  160  210 

20  182  257 

186  214 

31  230 240 

21  190 210 

27  230 280 

33  190  190 

210  230 

22 210 200 

23  210 200 

20  190  200 

24  ISO 140 

25  210 220 

194 192 

Average.  19S  211 

Dementia  Paralytica 


36 

38 
39 
40 

41 
42 


200 
180 
248 
260 

200 
ISO 


260 
190 

167 
240 
180 
230 


43 
44 
45 
47 
48 
49 
SO 


•350 
220 
210 
230 
170 
180 
180 


Average  206 211   Average.  220 


290 
200 
210 
240 
210 


230 


26 

27 
28 
28 


Depression 

200 

..-.  279  244 


228 

. .  170  210 

216  227 

34  240  300 

17  (fe)..   186  248 

213   274 

Average  215  246 


51 

52 
53 
54 


Epileptic 

. .  270  250 

, . .  200  200 

,. .  190  210 

...  170  200 


Average  207  215 


Discussion  of  the  Table  of  Minimal  Reactions  (Table  V) 

In  some  respects  the  minimal  reactions  for  any  well-established 
type  of  reaction  is  more  instructive  than  the  average  reaction. 
The  minimal  reaction  shows  the  reflex  systematization  in  its 
highest  state  of  efficiency.  The  mean  reaction  indicates  the 
average  state  of  efficiency.  The  two  differ  from  one  another  by 
the  mean  value  of  all  those  disturbing  elements  that  may  com- 
plicate the  reaction-process.  It  seems  to  the  writers  a  very  sig- 
nificant fact  that  the  average  minimal  reaction  of  extreme  mania- 


OCULAR   REACTIONS    IN    THE   PSYCHOSES  1 8/ 

cal  excitement  is  below  the  average  minimum  of  normal  subjects. 
It  is  not  much  below  the  normal,  but  it  is  not  above  it  as  the 
total  average  is.  Moreover,  the  mean  variation  of  the  minimal 
reactions  is  approximately  the  same  as  the  mean  variations  of  the 
averages.  This  consistent  uniformity  is  not  accidental.  In  con- 
nection with  the  adequate  pursuit-reactions  it  seems  to  the  writers 
to  constitute  unequivocal  evidence  that  the  oculo-motor  systemat- 
ization  is  not  seriously  disordered  in  acute  mania.  The  large 
mean  value  of  disturbing  elements  constitutes  the  final  point  that 
we  have  to  offer  in  the  cumulative  experimental  evidence  that 
extreme  mania  involves  a  marked  disturbance  of  the  controls 
normally  exercised  by  the  superior  central  systematizations. 

This  seems  to  the  writers  to  coincide  closely  with  the  general 
clinical  picture  of  marked  mania.  The  motor  organization  even 
for  complex  acts  is  not  lost.  The  incapacity  for  regular  employ- 
ment is  flagrantly  due  to  gross  disturbances  of  the  normal  con- 
trols within  the  higher  systematizations.  Tentatively,  at  least,  we 
may  picture  this  in  terms  of  an  inhibition  of  the  free  interaction 
of  the  various  factors  in  the  normal  complex  superior  organiza- 
tion. 

Provided  there  is  some  intrinsic  retardation  of  the  intermediate 
systematizations,  like  the  simple  oculo-motor  reflexes,  we  should 
expect  to  find  the  total  evidences  of  maniacal  excitement  less 
marked.  In  such  cases  we  should  expect  the  minimal  reactions  to 
be  long  as  well  as  the  average  reactions.  This  is  actually  the  case 
in  less  marked  mania.  It  looks  as  though  the  inhibitory  processes 
involved  in  the  disease  were  affecting  lower  centres.  The  climax 
of  this  downward  progression  seems  to  be  reached  when,  in 
extreme  depression,  the  resistance  to  neutral  interaction  involves 
the  simplest  reflexes. 

In  contrast  to  the  differential  increase  of  resistance  to  neural 
activity  as  found  in  the  manic-depressives,  our  experimental  data 
from  the  demented  point  to  a  general  disorganization  of  the 
central  systematizations. 

In  dementia  paralytica  the  entire  nervous  system  is  involved  in 
this  disorganization,  as  is  shown  by  the  marked  retardation,  and 
the  inefficiency  of  the  simplest,  as  well  as  of  the  higher  reflexes 
(patellar,  pupillary,  and  cerebellar). 

In  prcTCOx  the  disorganizations  seem  to  be  primarily  limited  to 


1 88  OCULAR   REACTIONS   IN    THE   PSYCHOSES 

the  superior  systematizations.  This  is  shown  negatively  by  the 
rapid  eye-movements,  normal  oculo-motor  reactions,  and  posi- 
tively by  the  difficulty  of  adopting  adequate  reactions  to  new 
conditions  of  the  environment,  as  in  the  pursuit-movements. 
This  latter  peculiarity  of  prsecox  patients  has  a  practical  as  well 
as  a  theoretical  interest. 

Practically,  it  is  an  important  differentiating  symptom  between 
moderate  maniacal  excitement  and  developing  prsecox,  i.  e.,  be- 
tween two  psychoses  whose  differential  diagnosis  is  of  the  utmost 
importance  and  often  of  the  utmost  difficulty.  Unfortunately  the 
faultiness  of  the  pursuit  is  not  easily  detected  by  direct  observa- 
tion. Photographic  registration,  although  remarkably  simple  as 
a  scientific  technique,  is  rather  too  expensive  in  time  and  appa- 
ratus for  regular  professional  use.  If  the  matter  prove  worth 
while,  a  simplified  recording  apparatus  is  probably  the  only  safe 
and  practicable  solution.  It  would  seem  strange,  however,  if 
similar  phenomena  cannot  be  found  in  other  forms  of  reaction 
which  are  more  accessible  to  direct  observation. 

The  theoretical  bearing  of  the  inadequate  ocular  pursuit-move- 
ments of  prsecox  we  have  already  mentioned.  It  was  not  over- 
looked by  us  that  the  simplest  explanation  of  the  phenomenon 
would  be  to  coordinate  it  with  those  processes  which  are  ordi- 
narily grouped  under  the  head  of  faulty  attention.  This  ex- 
planation seems  to  us  untenable  on  the  following  grounds : 

1.  Equally  grave  defects  of  "attention"  exist  in  maniacal  ex- 
citement without  parallel  difficulty  of  pursuit. 

2.  The  reaction-times  do  not  indicate  gross  defects  of  "  atten- 
tion "  in  moderate  prsecox. 

3.  Reasonable  "  attention  "  and  effort  at  pursuit  are  both  clearly 
indicated  in  the  number  and  character  of  the  short  corrective 
movements. 

Finally,  the  phenomenon  seems  to  connect  itself  naturally  with 
certain  characteristic  clinical  observations  of  prsecox  as  one  man- 
ifestation of  the  patient's  inability  to  adapt  himself  to  new  and 
unusual  requirements  of  his  environment.  Put  technically,  it  is 
the  patient's  inability  to  adopt  adequate  short-lived  habits  in 
response  to  a  new  recurrent  situation.  There  is  some  clinical 
evidence  that  this  motor  phenomenon  rests  on  a  basis  of  faulty 
elaboration  of  the  perceptual  data.     Our   experiments   indicate 


OCULAR   REACTIONS    IN    THE    PSYCHOSES 


189 


:       '.    \  !      \      ..  \  •.     •. 

\  \  \       \    \  /        \         \\ 


I   / 


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i      t 

I       t 

i   I 

n 


i 


I   f    I    ;  / 

/(J       ff 


no  11         14  20  25  25      54  34-  36         41 

Normal       Mania  Depressed      Praccox 

Plate  II 


I  r 


\\ 


I  \      \     \ 

1  in 


y      / 


I    M  / 


^      : 
C      : 


43  43  47  48      51  52>     52 
D.Paralylica  Epileplics 


Plate  II  is  reproduced  from  drawings  of  typical  pursuit-reaction  records. 
It  shows  most  of  the  typical  variations  of  the  visual  pursuits  so  far  as 
they  were  not  complicated  by  gross  head-movements.  The  lines  accurately 
reproduce  only  the  general  configuration  of  the  pursuit. 

Each  line,  reading  from  the  bottom  up,  represents  one  complete  pursuit- 
swing  corresponding  to  a  double  oscillation  of  the  second  pendulum.  Since 
the  release  of  the  pendulum  and  the  beginning  of  the  record  are  synchron- 
ous, the  straight  line  at  the  beginning  of  each  record  gives  the  reaction- 
time.  The  reaction  begins  with  a  sharp  horizontal  movement  to  the  right. 
This  is  followed  by  the  slow  pursuit  swing,  which  is  more  or  less  ade- 
quate according  to  the  nature  of  the  disease.  The  praecox  pursuits,  nos. 
36  and  41,  are  typical.  In  mild  cases  the  hesitation  to  adopt  the  pursuit- 
swing  is  less  pronounced,  but  it  is  regularly  shown  by  straight  lines  some- 
where in  the  pursuit.  The  maniacal  pursuit  shows  a  tendency  to  get  ahead 
of  the  pendulum  (see  upper  part  of  lines  14,  23  and  25).  This  tendency 
sometimes  appears  in  the  first  positive  acceleration  of  the  pendulum  in 
maniacal  cases.  It  is  not  entirely  absent  from  normal  pursuits  or  from 
moderate  depression.  In  the  latter  cases,  however,  it  is  very  rare.  Other 
modifications  of  the  pursuit  are  suggestive,  but  at  present  they  permit  no 
generalized  statement. 

The  double  breaks  in  each  record  are  occasioned  by  the  swinging  of  the 
pendulum  through  the  recording  beam  of  light. 


190  OCULAR   REACTIONS    IN    THE   PSYCHOSES 

that  the  intellectual  defect  is  a  matter  of  inadequate  appreciation 
rather  than  a  matter  of  attention. 

The  writers  take  the  opportunity  to  express  to  Dr.  H.  S.  Noble, 
superintendent  of  the  Connecticut  Hospital  for  the  Insane,  their 
cordial  appreciation  of  his  sympathetic  interest  and  encourage- 
ment which  made  this  series  of  experiments  possible. 

The  appendix  containing  a  brief  account  of  each  case  by  Dr. 
Diefendorf,  together  with  all  the  experimental  comparative  data 
from  the  photographic  records,  may  be  consulted  in  original 
article.  Brain,  CXIII,  1908. 

BIBLIOGRAPHY 
Mechanical  Registration  of  the  Eye-Movements 

1.  Delabarre,    E.    B.     "A    Method   of    Recording    the    Eye-Movements," 

Amer.  Joura  Psych,  Vol.  IX,  pp.  572-574. 

2.  Huey,    E.    B.     "  Preliminary    Experiments    in    the    Physiology    and 

Psychology  of  Reading,"  Amer.  Journ.  Psych.,  Vol.  IX,  pp.  575-586 

3.  Idem.     "  On    the    Physiology    and    Psychology    of    Reading,"    Amer. 

Journ.  Psych.,  Vol.  XI,  pp.  283-302. 

Photographic  Registration  of  the  Eye-Movement 

4.  Cameron,   E.   H.,  and   Steele,   W.   M.    "The   Poggendorflf  Illusions," 

Yale  Studies,  Vol.  I,  No.  i,  pp.  83-in. 

5.  Dearborn,   A.   F.     "Retinal  Local  Signs,"   Psych.  Rev.,  Vol.  XI,   pp. 

297-307. 

6.  Idem.     "  The  Psychology  of  Reading,"  Arch.  Philos.,  Psych.,  and  Sci. 

Method,  No.  4. 

7.  Dodge,  R.     "  Five  Types  of  Eye-Movement  in  the  Horizontal  Meridian 

Plane  of  the  Field  of  Regard,"  Amer.  Journ,  Physiol.,  Vol.  VIII, 

pp.  307-329. 

8.  Idem.     "  An  Experimental  Study  of  Visual  Fixation,"  "  Studies  from 

the  Psych.  Lab.  of  Wesleyan  Univ.,"  Vol.  I,  Psych.  Rev.  Monograph 
Supplements,  Vol.  VIII,  No.  4. 

9.  Idem  and  Cline,  T.  S.     "The  Angle- Velocity  of  the  Eye-Movements," 

Psych.  Rev.,  Vol.  VIII,  pp.  145-157. 
TO.  Holt,  E.  B.       "  Eye-Movements  during  Dizziness,"  "  Harvard  Psycho- 
logical Studies,"  Vol.  II,  pp.  57  fol. 

11.  Judd,  C.  H.     "The  Miiller-Lyer  Illusion,"  Yale  Studies,  Vol.  I,  No.  i, 

pp.  55-82. 

12.  Idem.     "  Photographic    Records    of    Convergence    and    Divergence," 

Yale  Pbychological  Studies,  Vol.  I,  No.  2,  pp.  370-423,  Psych.  Rev. 
Monograph  Supplement,  Vol.  VIII,  No.  3. 

13.  Idem    and    Courten,    H.    C.     "  The   Zoellner    Illusion,"    Yale    Studies, 

Vol.  I,  No.  I,  pp.  1 12-140. 


OCULAR   REACTIONS    IN    THE   PSYCHOSES  I9I 

14.  Idem,  McAllister,  C.  N.,  and  Steele,  W.  M.     "  Introduction  to  a  Series 

of  Studies  of  Eye-Movements  by  means  of  Kinetoscopic  Photog- 
raphs," Monograph  Supplement  of  the  Psych.  Rev.,  Vol.  VII,  Yale 
Psychological  Studies,  Vol.  I,  pp.  1-16. 

15.  McAllister,   C.   N.     "Fixation   of   Points   in  the  Visual   Field,"  Yale 

Studies,  Vol.  I,  No.  i,  pp.  17-54. 

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Philos.  Studien,  Bd.  XX,  S.  336. 


CYCLOTHYMIA— THE   MILD   FORMS  OF   MANIC- 
DEPRESSIVE  PSYCHOSES  AND  THE  MANIC- 
DEPRESSIVE  CONSTITUTION 

By  Smith  Ely  Jelliffe,  M.D.,  Ph.D. 

ATTENDING   NEUROLOGIST,   CITY   HOSPITAL  ;   CLINICAL  PROFESSOR  OF  PSYCHIATRY, 

FORDHAM    UNIVERSITY 

The  history  of  the  development  of  the  concept  of  a  manic- 
depressive  psychosis  is  one  of  the  most  striking  of  comparatively 
modern  psychiatric  generalizations. 

The  generalization  that  general  paresis  was,  in  the  mental  realm, 
a  disease  entity,  in  the  final  fashioning  of  which  Falret  Sr.^  played 
so  important  a  part,  naturally  led  the  alienists  of  the  times  to 
search  for  other  types  which  from  the  same  standpoint  of  entity 
as  to  clinical  picture  might  offer  permanency  to  the  then  rapidly 
disintegrating  systems  of  Pinel  and  Esquirol. 

The  meed  of  praise  given  to  Kahlbaum  for  his  insistence  on 
the  study  of  clinical  pictures  as  a  whole,  and  which  has  enriched 
our  present  psychiatric  museum  with  such  species  and  pseudo 
species  as  hebephrenia,  catatonia,  etc.,  has  perhaps  been  exagger- 
ated. Kahlbaum  was  far  from  being  the  first  advocate  of  this 
slogan,  so  vigorously  uttered  by  the  present  day  school.  Falret 
Sr.'s  writings  are  many  and  unequivocal  on  this  point,  and  ante- 
date Kahlbaum's  paper  on  the  Grouping  of  Mental  Diseases.  In 
his  Principles  of  Classification,  i860,  the  newer  and  broader  stand- 
point is  shown  throughout,  and  in  his  delightful  and  valuable 
(even  for  the  purposes  of  present  day  psychiatry)  discourse  on 
Folic  Raisonnante  (January,  1866)  one  finds  him  stating  again 
and  again  that  psychiatry  has  suffered  too  much  from  the  follow- 
ing of  kaleidoscopically  varying  symptom  pictures,  regardless  of 
the  clinical  course. 

It  was  this  clear  view  of  what  must  be  borne  in  mind,  in  order 
to  posit  a  psychosis  of  itself  that  led  him  to  the  amplification  and 

^Recherches  sur  la  folic  paralytiques  et  !es  divcrses  paralysies  generales. 
These  Inaugurale.     Paris,  May  30,  1853. 

14  193 


194  CYCLOTHYMIA 

the  clearer  precision  of  "  folic  circulaire  "  as  it  had  been  originally 
described  by  his  father  and  Baillarger  in  1854.^ 

His  father  and  himself,  writes  Jules  Falret,^  have  had  the  rare 
opportunity  to  have  been  able  to  observe  in  three  different  families 
the  existence  of  this  form  of  mental  disease  perpetuated  in  three 
generations ;  the  grandmother,  mother  and  daughter,  and  all  with 
the  same  form. 

A  point  of  interest  historically  is  that  Falret,  Jr.,  used  the  terms 
"mixed  states  "  (p.  619)  in  his  paper  on  folic  circulaire,  but  gives 
no  characterization  of  what  he  meant  other  than  transitional 
periods  between  successive  phases. 

The  point  of  present  active  interest  concerns  itself  with  Jules 
Falret's  clear  recognition  of  the  attenuated  types  of  his  folic 
circulaire.  It  will  prove  of  interest  to  gather  here  what  this 
author  says  of  them.  Later  they  may  be  compared  with  contem- 
poraneous German  ideas.  Falret  first  states  that  (p.  602,  fitudes 
Cliniques,  1890)  folic  circulaire  is  (as  defined)  an  hereditary 
affection,  and  generally  found  in  a  similar  form  in  both  ascendants 
and  descendants.  Speaking  of  attenuated  forms  observed  in  the 
world  at  large  (p.  604,  1.  c.)  he  says,  "  In  the  first  place  there  is  a 
first  category  of  facts  which  it  is  of  importance  to  point  out  above 
all  from  the  point  of  view  of  practical  psychiatry  and  of  juris- 
prudence. One  does  not  often  enough  appreciate,  and  certainly 
one  cannot  too  often  repeat  that  one  frequently  observes,  both  in 
the  family  circle  and  in  society  at  large  individuals  who  are  not 
considered  as  sick,  even  less  as  mentally  afflicted,  and  whose  en- 
tire lives  are  passed,  isolated  for  the  most  part  by  the  people 
who  surround  them  in  a  successive  round  of  periods  of  moderate 
excitement  and  of  slightly  pronounced  melancholy,  and  who  are 
in  reality  afflicted  in  an  evident  degree,  but  more  attenuated,  with 
this  form  of  mental  malady.  They  continue  to  live  the  life  of  the 
community,  or  the  family  life  without  its  being  necessary  to  treat 
them  as  sick  individuals,  even  quite  far  from  considering  them  as 
having  a  psychosis,  and  above  all  of  shutting  them  up  in  asylums. 
So  much  so  that,  when  in  a  period  of  excitement,  these  individ- 
uals simply  appear  to  have  changed  their  character,  and  to  have 

"  See  also  J.   P.   Falret.      La  Manie  sans  delire.      These,   1849.     J.   P. 
Falret:  Gaz.  de  Hop.,  1851. 

^La  folie  circulaire.    Arch.  Gen.  de  Med.,  Dec.  28,  1878.  Jan.,  1879. 


CYCLOTHYMIA  1 95 

momentarily  acquired  an  unaccustomed  activity.  They  occupy 
themselves  with  business;  they  make  numerous  visits,  they  write 
letters  to  those  that  they  are  not  in  the  habit  of  visiting  frequently ; 
they  have  a  desire  to  be  incessantly  on  the  move ;  they  sleep  very 
little,  make  numerous  trips  or  projects.  They  take  up,  with 
feverish  activity,  the  duties  of  their  profession,  or  even  take  up 
new  business  schemes  which  they  seek  to  advance  to  a  state  com- 
parable with  their  habitual  occupations.  They  show,  on  all  occa- 
sions, an  exaggerated  gaiety.  They  show  themselves  to  be  intel- 
ligent, loquacious,  and  even  spiritual,  and  although  there  may  be 
always  present  great  disorder  in  their  acts,  and  a  certain  discon- 
nectedness in  their  speech,  those  who  have  not  known  them  for 
some  time,  or  those  who  have  not  observed  them  at  other  times, 
are  unable  to  judge  of  their  true  mental  situation,  although  the 
diseased  nature  of  this  state  does  not  escape  an  attentive  observer, 
and  is  often  appreciated  with  exactness  by  the  members  of  their 
families  or  by  those  who  live  habitually  with  them. 

This  diseased  character  then  manifests  itself  otherwise  when 
after  a  more  or  less  prolonged  period  of  excitation,  which  has 
passed  for  a  simple  change  of  character,  there  supervenes  little 
by  little,  or  all  at  once  in  those  individuals  who,  up  to  then,  had 
shown  gaiety  and  an  exaggerated  activity,  a  state  precisely  the 
reverse,  to  such  a  degree  that  one  would  believe  they  had  to  do 
with  two  different  individuals.  Instead  of  showing  this  exuberant 
activity  which  seems  to  feel  neither  fatigue  nor  the  need  for  rest, 
these  patients  cease  to  go  out,  to  make  calls,  to  do  business.  They 
change  their  character  completely :  they  become  sedentary,  incom- 
municative, almost  mute ;  they  flee  from  the  world,  seek  solitude 
and  isolation ;  speak  little,  or  reply  briefly  to  questions  addressed 
to  them,  complain  of  general  malaise,  of  a  very  sad  state  of  suf- 
fering, of  praecordial  anxiety,  of  loss  of  appetite;  they  are  sad, 
unhappy,  anxious  without  reason,  or  for  slight  occasion.  They 
are  conscious  of  their  own  condition  and  regret  it,  but  cannot  be 
brought  to  modify  them ;  they  thus  come  to  acquire  a  distaste  for 
living,  to  refuse  food,  and  in  extreme  cases,  they  shut  themselves 
up  in  their  rooms  for  several  months ;  without  attracting  in  a 
notable  manner  the  attention  of  those  about  them,  especially  when 
one  knows  that  they  are  the  subjects  of  what  one  vulgarly  calls 
"  black  humors,"  "  the  blues." 


196  CYCLOTHYMIA 

As  to  the  public,  they  see  these  people  only  from  time  to  time, 
and  have  no  occasion  to  see  them  when  they  are  shut  up  at  home ; 
they  cannot  doubt  the  diseased  state  in  which  they  are  found  for 
several  months,  and  when  they  see  them  appear  later  at  a  time 
when  the  period  of  excitation  surges  up,  they  then  refind  them 
such  as  they  had  known  them  before.  They  think  of  them  as 
eccentric  characters,  gay  and  lively,  and  of  feverish  activity  such 
as  they  have  observed  with  certain  individuals,  but  they  do  not 
suspect  the  existence  of  a  morbid  state  which  is  appreciable  only 
by  the  successive  reproduction  of  periods  of  excitation  and  of 
depression  which  the  world  is  not  called  upon  to  determine. 

Such  is  the  lightest  and  the  most  often  overlooked  phase  of 
folic  circulaire,  the  observation  of  which  rarely  obtains  within 
hospitals  for  the  insane. 

Falret  then  discusses  the  severer  grades  of  folic  circulaire,  such 
as  are  observed  in  the  asylums. 

That  psychoses  showing  periodic  attacks  have  been  recognized 
for  centuries  will  admit  of  no  question,  yet  I  cannot  permit  this 
opportunity  to  go  by  without  calling  in  question  the  hasty  gen- 
eralization that  has  been  widely  spread,  and  supported  by  so  good 
a  student  of  historical  problems  as  Farrar,*  that  Aretaeus  was 
really  the  father  of  manic-depressive  insanity.  Aretaeus  never 
dreamed  of  anything  like  the  modern  conception.  This  no  one 
will  doubt,  and  only  by  reason  of  a  definite  misinterpretation  of 
the  words  "  mania  "  and  "  melancholia,"  and  a  failure  to  realize 
what  these  words  meant  to  writers  of  the  early  centuries,  has  per- 
mitted such  an  erroneous  impression  to  originate. 

In  a  short  note  on  Hippocratic  psychiatry,^  I  have  again  called 
attention  to  what  has  long  been  known,  that  the  ancients  did  not 
use  the  words  mania  and  melancholia  in  any  sense  as  we  now 
employ  them.  Melancholia  was  not  at  all  synonymous  with  de- 
pressive conditions  as  a  whole.  It  was  used  to  designate  at  times 
the  wildest  excitement,  and  mania  was  used  more  as  synonymous 
with  insanity,  craziness,  etc.,  than  it  was  with  excitement.  Thus, 
for  instance,  the  word,  used  so  frequently  by  Aretaeus,  mania- 
melancholia,  is  interpretable  only  as  a  melancholic  insanity,  and 
might  have  included  some  excitements  as  well  as  some  depres- 

*  Some  Origins  in  Psychiatry,  Am.  J.  of  Insanity,  1909. 
^  Alienist  and  Neurologist,  Feb.,  1910. 


CYCLOTHYMIA  1 97 

sions.  In  the  passages  so  frequently  quoted  as  substantiating  the 
claim  that  Aretaeus  noticed  the  periodic  change  from  mania  to 
melanchoHa,  it  strikes  me  it  has  been  entirely  overlooked  that  he 
is  discussing  the  vexed  question  of  the  relation  of  hypochondria 
to  a  depressed  melancholia,  and  all  that  his  descriptions  really  say 
is  that  a  hypochondria  passes  over  into  a  depressed  melancholia. 
So  much  for  the  early  analogies  with  the  idea  of  manic-depressive 
insanity.  I  shall  hope  to  discuss  this  more  fully  later,  but  any  one 
who  will  read  Arnold's  historical  notes,  particularly  as  applied  to 
Aretaeus,  will  perceive  that  he  at  least  had  not  been  misled  into 
assuming  that  the  ancients  used  the  symbols  mania  and  melan- 
cholia as  we  use  them  to-day. 

But  this  is  a  pure  digression  into  the  historical  realm.  I  wish 
to  assume  the  reality  of  so  clear  a  syndrome  as  to  permit  us  to 
posit  the  belief  in  a  manic-depressive  psychosis.  Not  that  every- 
thing now  thought  of  as  belonging  to  this  psychosis  will  ultimately 
find  a  resting  place  there,  but  that  there  is  a  nucleus  in  the  con- 
stellation that  is  a  mental  disorder  in  as  definite  a  sense  as  paresis 
is  a  disorder,  or  that  there  is  a  dementia  praecox  nucleus  as  well. 

Personally  the  word  cyclothymia  seems  to  be  a  useful  one,  not 
perhaps  strictly  in  the  sense  as  first  proposed  by  Kahlbaum,  but 
as  a  concept  expressing  one  of  two  things,  or  both ;  namely,  mild 
grades  of  the  manic-depressive  psychosis,  and  the  constitutional 
features  that  underlie  such  personalities.  In  the  former  sense  it 
has  received  much  attention  from  the  hands  of  modern  writers, 
particularly  Willmans,  and  in  the  latter  has  achieved  some  popu- 
larity in  France  at  the  hands  of  Deny,  and  more  particularly  by 
Kahn.« 

The  work  of  Falret,  which  can  never  be  overlooked  in  the  his- 
tory of  the  development  of  the  ideas  of  the  manic-depressive 
psychosis,  cannot  now  be  reviewed,  but  a  brief  glance  at  Kahl- 
baum's  original  paper  may  be  of  interest.  Kahlbaum,  it  will  be 
recalled,  had  already  given  the  concepts  hebephrenia  and  cata- 
tonia somewhat  as  in  their  modern  cast.  In  his  paper  on  cyclical 
insanity''  he  adopts  Falret's  idea  of  a  cyclical  psychosis  as  one  of 
the  most  settled  features  in  psychiatry,  comparing  it  in  definite- 
ness  with  paresis  and  epilepsy.     He  speaks  of  it  as  extremely 

'  Cyclothymia,  1909. 

^  Ueber  cyklisches  Irresein.     Breslauer  aerztliche  Zeitschrift,  4,  1882. 


198  CYCLOTHYMIA 

common,  and  as  occurring  also  in  such  mild  grades  as  rarely  to 
come  to  the  attention  of  asylum  physicians.  He  defines  cyclical 
insanity  in  the  conventional  manner  of  periodic  attacks  of  excite- 
ment and  depression,  following  one  another  with  real  or  apparent 
sound  intervals,  and  with  a  certain  uniformity  in  the  symptom 
picture.  He  calls  attention  to  the  apparent  anomaly  of  the  alter- 
nating or  periodic  occurrence  of  two  such  strikingly  different 
types  of  mental  disorder  as  a  part  of  what  apparently  is  a  single 
disease  process,  marked  by  a  definite  chronicity.  He  then  speaks 
of  these,  not  as  two  separate  disease  forms,  but  as  two  stages 
occurring  in  the  same  disease.  Kahlbaum  (p.  218,  1.  c.)  is  in- 
clined to  believe  that  these  manic  and  melancholic  stages  are  dif- 
ferent from  what  he  would  term  ordinary  or  classical  manias  and 
melancholias,  and  gives  some  interesting  differentials  which  need 
not  detain  us  at  present. 

The  manic  phase  of  cyclical  insanity  differs  even  more  from 
classical  mania  than  does  the  depressive  phase  from  melancholia. 
The  folic  raissonante  of  the  French  expresses  best  the  manic 
phase  of  the  disorder. 

After  a  somewhat  lengthy  disquisition  on  philosophical  prin- 
ciples, Kahlbaum  returns  to  the  question  of  prognosis,  and  on  the 
basis  of  a  relatively  good  prognosis  on  the  one  hand  and  the  devel- 
opment of  a  secondary  dementia  on  the  other,  he  would  divide 
the  cases  of  cyclical  insanity  into  two  groups,  which  really  should 
be  considered  as  things  quite  different  one  from  another.  On  the 
one  hand  one  has  a  partial  disturbance  of  the  mind,  a  primary 
disorder  of  the  feelings,  a  true  emotional  disorder,  the  other  is  a 
total  disorder,  affecting  all  three  portions  of  the  soul  life,  intellect, 
will,  and  feelings,  and  results  in  degeneration.  Vesania  typica 
circularis  he  proposes  to  call  the  latter,  and  he  coins  the  word 
cyclothymia  (Cyclothymic,  p.  221,  1.  c.)  for  the  former. 

A  true  depression  remaining  as  such,  and  not  a  depressed  phase 
of  a  circular  insanity,  he  terms  with  Fleming  a  dysthemia,  while 
a  manic  state  is  a  hyperthemia.  Thus  the  simple  emotional  psy- 
choses are  dysthemia  and  hyperthemia,  and  their  combination  a 
cyclothymia.  Kahlbaum  apparently  never  developed  his  ideas 
further,  and  gives  no  detailed  description. 

Hecker,  Kahlbaum's  follower,  seemed  to  take  up  the  same  task 
as  he  undertook  in  the  case  of  hebephrenia,  namely,  that  of  popu- 


CYCLOTHYMIA  1 99 

larizing  his  teacher's  early  descriptions,  for  some  sixteen  years 
later  in  a  paper  on  Die  Cyclothymie,  eine  circulare  Gemiithser- 
krankung,^  he  adopts  Kahlbaum's  term  and  discusses  its  symptom- 
atology, differential  diagnosis,  and  treatment. 

Hecker  first  acknowledges  his  indebtedness  to  Kahlbaum  and 
accentuates  the  nondementing  feature  that  should  characterize 
cyclothymia  from  others  of  the  periodic  psychoses.  Cyclothymia 
is  solely  an  alternation  of  a  dysthemia  and  a  hyperthemia  indicat- 
ing variations  in  the  emotional  tone  of  the  patient  with  intact  intel- 
lectual faculties.  Here  it  may  be  noted  that  Hecker  calls  attention 
to  Kraepelin's  tentative  adherence  to  Kahlbaum's  general  thesis. 

Hecker  makes  the  acute  observation  that  whereas  the  depressive 
phases  in  the  cycle  fall  under  the  ban  of  suspicion  as  psychotic, 
it  is  only  rarely  that  the  milder  excited  periods  are  recognized  as 
pathological.  Hence  the  astonishing  number  of  periodic  depres- 
sions which  are  noted  and  described  in  psychiatric  literature,  but 
a  dearth  of  periodic  mild  excitements.  He  writes  that  in  ordinary 
practice  they  are  diagnosed  as  neurasthenics.  At  present  we  find 
them  largely  parading  under  the  more  modern  symbol  psychas- 
thenia.  The  patients  are  for  the  most  part  treated  for  their  fan- 
cied physical  ailments. 

The  chief  and  fundamental  symptom  of  the  depressive  stage  of 
cyclothymia  is  the  psychical  retardation  with  absence  of  all  delu- 
sions or  hallucinations  associated  with  an  intense  and  definite, 
even  though  not  always  correct,  insight.  The  patients  complain, 
in  the  first  place,  and  continuously,  of  their  loss  of  ability  to  do 
mental  work.  They  have  the  feeling  that  they  will  never  be  able 
to  do  any  more  work,  and  that  they  do  everything  upside  down ; 
of  their  indifference  to  persons  and  things  which  had  been  of  great 
interest  to  them.  They  describe  their  condition  as  an  inward 
hardening,  a  stoniness,  as  though  there  were  a  curtain,  a  wall, 
or  what  not  between  them  and  the  world.  Every  resolution  is 
difficult,  all  action  an  affliction.  They  must  be  pushed  to  accom- 
plish anything;  prefer  to  be  left  alone,  and  reject  the  overtures 
of  friends  because  it  may  be  necessary  to  talk  to  them.  Many 
wish  to  remain  in  bed  all  day  in  order  to  be  relieved  of  all  duties. 
Others  again,  in  spite  of  their  internal  conflicts,  are  able  to  so 
comport  themselves  before  the  public  as  to  avoid  notice.     When 

'Zeitschrift  fiir  praktische  Aerzte,  7,  1898,  p.  6. 


200  CYCLOTHYMIA 

such  begin  to  express  their  troubles  they  are  usually  regarded  by 
those  about  them  as  imaginary.  This  judgment  is  all  the  more 
often  made  by  the  laity,  especially  when  some  symptoms  of  excite- 
ment are  interspersed  with  the  depressed  ones.  One  symptom  in 
particular  is  noticeable  by  reason  of  its  contrast  with  the  patient's 
complaints  of  apathy  and  indiflference ;  this  is  a  very  striking 
tendency  to  and  capacity  for  criticism.  The  patients  see  every- 
thing and  feel  a  thousand  little  things  as  inconvenient  and  dis- 
turbing quite  in  contrast  to  the  true  melancholic.  They  complain 
of  incompleteness  in  the  arrangement  of  the  rooms,  complain  of 
the  food,  of  the  service,  often  not  without  foundation,  but  quite 
in  contradiction  to  their  expressed  state  of  indiflference  to  the 
world  at  large. 

Hecker  further  states  that  it  is  extremely  common  for  these 
patients  to  occpy  their  minds  with  suicidal  ideas,  and  that  fre- 
quent talking  about  it  seems  to  afiford  some  relief.  The  whole 
condition  is  often  likened  by  the  patient  to  a  machine  whose  oil 
is  dried  up,  while  in  the  contrasting  state  the  patients  speak  of 
the  machine  as  too  well  lubricated. 

This  latter  state,  which  Hecker  says  Kraepelin  terms  "hypo- 
mania,"  and  Schiile  "  mania  mitis,"  or  "  mania  mitissima,"  which 
he  observes  are  to  be  considered  as  more  fully  developed  forms, 
shows  a  marked  contrast  with  the  former  state.  The  patients 
feel  themselves  the  sense  of  well  being,  they  are  wittier,  cleverer 
and  more  capable  than  on  healthy  days.  The  tendency  to  fault 
finding,  which,  as  has  been  seen,  is  present  in  the  depressed  phase, 
is  strikingly  amplified  or  modified.  These  patients  often  have  a 
very  scornful,  mocking  attitude,  and  the  internal  unrest  leads  to 
more  or  less  exaggerated  activity.  Not  only  can  these  patients 
stand  more  continuous  work  than  on  their  well  days,  but  not 
infrequently  is  the  character  of  the  work  a  great  deal  better. 
Often  those  of  minor  musical  talent  rise  to  heights  rarely  reached, 
and  in  matters  of  artistic  merit  others  reach  a  higher  level  than 
ever.  Some  show  a  skill  in  literary  production  rarely  equalled  in 
their  normal  phases.  The  biography  of  the  "  Mind  that  Found 
Itself"  is  an  evidence  of  this  cyclothymic  activity  after  a  re- 
covered cycle  of  a  marked  depression  and  manic  cycle  in  an  acute 
psychotic  outbreak. 

Life  is  seen  now  only  on  its  rosy  side.    The  desire  to  help  every- 


CYCLOTHYMIA  20I 

body  and  interest  themselves  in  everything  is  manifest  through- 
out. Much  philanthropic  overactivity  and  many  reform  propa- 
ganda receive  their  greatest  stimuli  from  minds  in  this  hypomanic 
stage. 

Hecker  relates  an  instance  of  multiple  marriage  engagements 
made  in  the  euphoric  state  and  broken  in  the  depressive  phase  in 
a  patient  with  cyclothymia. 

In  the  mild  stages,  patients  with  cyclothymia  are  regarded  as 
normal.  So  soon,  however,  as  the  disorder  develops  a  little  more, 
as  it  is  apt  to  do  in  some,  if  not  all,  of  its  attacks,  a  series  of  more 
striking  symptoms  arise.  There  is  a  great  tendency  on  the  part 
of  the  patients  to  be  extravagant  and  careless  in  their  purchases, 
a  tendency  to  run  about  and  to  peculiar  actions  which  the  patients 
themselves  reason  about  with  keen  relish,  an  abnormal  sense  of 
the  ego,  the  wish  to  push  oneself  forward  constantly,  an  exagger- 
ated desire  to  bedeck  oneself  with  badges  or  other  evidences  of 
accomplishment,  medals,  ribbons,  buttons,  etc.  Hecker  notes  that 
not  infrequently  patients  in  this  state  have  been  mistaken  for 
paretics,  a  mistake  which  the  writer  has  had  occasion  to  observe 
three  times  in  the  past  six  months. 

In  certain  patients,  Hecker  writes,  one  finds  the  abnormal  devel- 
opment of  lying  and  drinking  tendencies  and  the  desire  to  frequent 
resorts  of  a  questionable  character. 

Symptoms 

I  do  not  purpose  to  discuss  the  symptoms  of  the  more  frank 
manic  depressive  psychosis,  but  wish  to  call  attention  to  some  of 
the  signs,  at  times  slight  in  themselves,  at  times  appearing  isolated 
— again  in  combination,  which  are  indicative  of  the  manic-depres- 
sive make  up,  and  of  the  milder  types  of  this  psychosis,  to  which 
we  have  thought  to  give  the  name  cyclothymia  originally  proposed 
by  Kahlbaum. 

As  to  the  former,  the  signs  of  cyclothymic  constitution,  there  is 
much  to  learn.  Our  casuistic  contributions  as  yet  are  meager,  and 
offer  only  tentative  and  suggestive  material,  rather  than  funda- 
mentals which  admit  of  no  controversy.  As  I  purpose  to  take  this 
matter  up  in  a  separate  communication  I  shall  omit  its  further 
consideration  at  this  time. 


202  CYCLOTHYMIA 

In  the  definite  depressive  phase  of  the  manic-depressive  psy- 
chosis, it  is  well  known  that  complaints  of  physical  ailments  are 
extremely  common  and  persistent,  but  the  mental  picture  is  so 
apparent  that  the  foundation  for  the  belief  in  the  physical  illness 
is  recognized  at  its  true  value,  and  rightly  dismissed  from  the 
foreground  in  the  therapeutic  attack.  This,  however,  is  not  the 
case  with  the  cyclothymic.  Here  every  efifort  is  made  to  conceal 
the  mental  disturbance,  to  minimize  it,  and  as  a  corollary  one 
finds  a  corresponding  enhancing  of  the  complaints  of  physical 
distress.  The  depressed  cyclothymic  hides  his  mental  trouble 
because  he  has  insight,  and  does  not  desire  to  be  considered  men- 
tally ill,  and  thus  pushes  the  physical  into  the  foreground,  per- 
haps himself  believing  it  to  be  the  source  of  his  depression  of 
spirits. 

Such  patients  may  be  seen  at  any  and  at  all  times  in  the  con- 
sultation rooms  of  the  gynecologist,  the  laryngologist,  the  oph- 
thalmologist, the  internist,  and  above  all  the  gastro-enterologist. 
These  patients  are  not  the  false  gynopaths,  the  false  cardiopaths, 
the  false  gastropaths,  and  enteropaths  of  Dejerine — at  least  many 
of  them  are  not — these  make  up  still  another  category,  but  are 
true  cyclothymic  cases  in  the  depressed  phase.  They  are  treated 
for  weeks,  or  even  months — get  well — swell  the  statistics  of 
favorable  action  of  this  or  that  operation,  this  or  that  remedy,  not 
to  mention  the  cofifers  of  the  enthusiastic,  but  blind  specialist, 
and  then  go  through  another  series  of  gynecological  tinkering,  of 
nose  and  throat  sprays,  of  refitting  of  glasses,  of  stomach  wash- 
ing and  of  intestinal  medication.  Some  of  these  cyclothymics 
never  pass  out  of  the  mild  class  of  attacks  and  their  affection  is 
rarely  recognized.  With  others,  however,  the  onset  of  a  more 
severe  manic  or  depressed  attack  affords  the  clue  to  the  interpre- 
tation of  the  whole  process. 

In  a  restricted  sense  every  mental  disorder  is  a  disorder  of  the 
entire  organism  since  every  organ  of  the  body  has  a  definite 
cortical  representation.  In  the  cyclothymic  this  relation  of  the 
brain  to  the  somatic  organs  is  strikingly  illustrated  and  both  vaso- 
motor and  secretory  anomalies  are  almost  constant  accompani- 
ments. The  cessation  of  the  menses,  the  diminution  of  the  salivary' 
and  renal  secretions,  and  disturbances  of  the  intestinal  canal  are 
among  the  most  striking  of  these  abnormalities,  and  not  enough 


CYCLOTHYMIA  2O3 

weight  has  been  put  especially  upon  the  latter.  I  can  take  up 
only  a  few  of  these  types  in  the  restricted  time  at  my  disposal. 

Gastro-enterological  Types. — In  the  vast  majority  of  cyclo- 
thymic attacks  in  the  depressed  phase,  there  are  present  very 
definite  and  tangible  disturbances  of  the  gastro-intestinal  tract. 
The  so-called  nervous  dyspepsias  are  in  great  part  cyclothymic, 
and  it  behooves  our  gastro-enterologists  to  recognize  such  forms 
and  desist  from  useless  therapeutic  attempts.  Kahn  has  likened 
these  attacks  to  a  prodromal  aura.  There  are  many  classical 
illustrations  in  Raymond  and  Janets'  works,  where  these  cases 
are  described  under  the  diagnosis  of  obsessions,  neurasthenias  and 
psychasthenias. 

These  cyclothymic  digestive  disorders  are  not  stereotyped. 
Constipation  is  usual,  and  some  slight  dulness  of  mind,  with  per- 
sistent dull  headaches  and  frequently  restlessness  and  sleepless- 
ness, although  sleep  disturbances  seem  more  pronounced  in  those 
attacks  which  show  a  slightly  manic  tinge.  In  the  depressive 
attacks  which  usually  pass  under  the  head  of  nervous  dyspepsia^ 
— neurasthenia  and  the  like,  the  mood  is  usually  plaintive  or  dis- 
tinctly cast  down.  Effort  is  largely  automatic,  and  lacks  spon- 
taneity. The  sense  of  being  driven  to  do  one's  work  is  marked, 
although  a  fairly  high  degree  of  efficiency  may  be  present.  Only 
the  necessary  things  are  attended  to,  and  some  of  these  neglected. 

The  receptivity  is  much  diminished.  Emotional  indifference 
is  frequent.  These  patients  recognize  their  laziness,  and  often 
take  refuge  behind  sententious  philosophy — "  that  life  is  hardly 
worth  the  candle  " — "  God  is  unjust " — but  they  rarely  weep,  nor 
show  any  marked  anxiety,  although  timidity  may  be  present. 

These  mental  symptoms  they  try  to  hide  and  instead  speak  of 
their  continued  loss  of  appetite,  their  diminishing  weight,  the 
bitter  taste  in  the  mouth,  the  acid  eructations.  They  feel  pres- 
sure in  the  body,  a  sense  of  stiffness  and  occasionally  have  pro- 
fuse diarrheal  discharge  following  marked  obstipation.  They 
have  marked  anxiety  and  believe  that  they  are  suffering  from 
ulcer  of  the  stomach,  or  that  carcinoma  is  present.  Careful  and 
tactful  suggestion  often  reduces  the  anxiety,  and  relieves  the 
patient  for  a  time,  but  the  symptoms  show  a  marked  tendency  to 

*  Dreyfus  :  Die  nervose  Dyspepsie,  1908. 


204  CYCLOTHYMIA 

remission  in  spite  of  negative  organic  findings  with  the  possible 
exception  of  a  markedly  reduced  motility,  which  is  a  result  of  the 
mental  depression. 

Flemming,  Schroder  van  der  Kalk,  Greisinger,  Kraft-Ebing, 
Schiile,  Alt,  and  most  of  the  older  psychiatrists,  regarded  the 
stomach  disturbances  as  primary  in  just  this  sort  of  case,  whereas 
it  seems  now  with  the  clear  definition  of  manic-depressive  insan- 
ity before  us  that  the  very  opposite  is  the  real  situation.  These 
patients  get  well  not  because  of  the  local  applications  or  the  local 
therapy,  but  because  the  cycle  has  run  its  course  or  that  proper 
mental  therapeutics  has  been  applied.  Some  of  the  most  striking 
cures — so-called — are  seen  in  disciples  of  osteopathy,  and  kindred 
sects. 

Dipsomaniacal  Types. — The  cyclothymic  constitution  and  mild 
attacks  of  cyclothymia  manifest  themselves  very  frequently  under 
the  guise  of  periodic  alcoholic  debauches.  In  the  former  case  the 
alcoholic  excesses  are  apt  to  be  fairly  short  in  duration,  and  are 
often  interspersed  with  periods  of  productive  energy,  often  in  the 
gifted  of  a  very  high  order  of  efficiency.  In  the  more  pronounced 
cyclothymic  attacks  the  debauches  have  a  tendency  to  be  much 
more  prolonged,  but  as  has  already  been  intimated,  hard  and  fast 
lines  are  not  to  be  drawn  between  the  attacks  which  may  be  re- 
garded as  purely  evidences  of  the  cyclothymic  constitution  or 
those  of  a  more  frank  outbreak  of  a  definite  psychosis. 

Illustrative  types  of  this  form  of  so-called  dipsomania  are  not 
difficult  to  find.  They  are  frequent  in  the  general  practitioner's 
work,  although  their  relationship  to  a  well  defined  psychosis  in 
a  minor  type  are  overlooked,  precisely  as  walking  typhoids  may 
be  disregarded.  Asylum  studies  are  usually  silent  regarding  this 
type  of  case.  General  literature  and  history  abounds  in  refer- 
ences to  this  type  of  phenomenon,  the  best  illustration  of  which 
perhaps  is  afforded  in  the  life  of  Alfred  de  Musset,  as  told  by  his 
brother,  Paul  de  Musset.  "  At  times^**  at  the  bottom  of  an  armoire 
he  had  an  old  yellow  box  coat,  with  six  mufflers,  and  which  could 
be  wrapped  about  him  three  times.  Thus  muffled  up,  he  would  lie 
down  on  the  floor  (tapis)  of  his  room  and  hum  in  a  lamentable 

"  Paul  de  Musset.     Bibliographie  d'  A.  de  Musset.     Charpentier,   1879, 
p.  91. 


CYCLOTHYMIA 


205 


tone  some  old  contemporaneous  air.  Then  in  the  evening  he 
would  cast  aside  these  rags  and  put  on  his  best  clothes.  This 
change  of  decoration  was  sufficient  to  turn  the  course  of  his  ideas ; 
he  would  leave  to  make  a  tour  of  the  cafes  of  Paris  where  the 
pleasures  of  the  world  made  him  forget  the  reverse  of  fate. 

Soon  he  would  be  in  a  fever  of  excitement.  .  .  .  One  spring 
evening,  says  Paul  de  Musset,  on  returning  from  a  walk,  Alfred 
recited  to  me  the  two  first  couplets  of  a  dialogue  between  the 
muse  and  the  poet  (La  nuit  de  Mai)  which  he  had  just  composed 
under  the  horse  chestnuts  of  the  Tulieries. 

He  worked  without  interruption  until  the  morning  when  he 
appeared  at  breakfast.  I  did  not  notice  any  signs  of  fatigue  on 
his  face.  He  had  as  his  Fantasio  the  month  of  May.  The  muse 
possessed  him.  During  the  day  he  would  take  the  lead  in  con- 
versation, and  work  like  a  chess  player  who  plays  two  games  at 
one  time.  At  times  he  would  leave  us  to  write  a  dozen  verses, 
and  then  would  return  to  chat  with  us.  But  at  night  he  returned 
to  work  as  he  would  to  a  lover's  rendezvous.  He  had  late  supper 
served  him  in  his  room.  He  purposely  asked  for  two  services,  in 
order  that  the  muse  should  have  her  place  designated. 

All  of  the  lights  were  lit.  He  lit  twelve  candles.  People  of 
the  house  seeing  this  illumination  would  think  he  was  giving  a 
ball.  On  the  morning  of  the  second  day,  the  piece  having  been 
accomplished,  the  muse  took  herself  away,  but  she  had  been  so 
well  received,  that  she  promised  to  return.  The  poet  blew  out  his 
candles,  went  to  bed  and  slept  until  evening.  On  awakening  he 
reread  the  verses,  and  could  find  nothing  to  retouch. 

After  the  inspiration — daughter  it  may  be  of  excitation — here 
is  the  other  stage.  Then  from  the  ideal  world  in  which  he  had 
lived  for  two  days,  the  man  fell  brusquely  to  earth,  sighing  as  if 
one  had  awakened  him  from  a  delicious  and  fairy-like  dream. 

After  the  enthusiasm  there  followed  all  at  once  an  ennui,  a  dis- 
taste for  ordinary  life,  and  from  its  petty  miseries,  a  deep  melan- 
choly. In  order  to  relieve  himself  from  such  a  depression,  it 
seemed  that  all  the  luxury  of  Sardanapolis,  all  that  Paris  could 
offer  of  distractions  and  of  refinements  could  hardly  suffice." 

And  then  Paul  de  Musset  adds — "in  the  eyes  of  most  people 


206  CYCLOTHYMIA 

these  alternations  of  over-excitement,  and  of  depression  are  only- 
weaknesses,  this  is  an  error. "^^ 

Georges  Sand^^  has  given  us  new  testimony  of  these  crises  of 
moods  (humeur). 

"  They  were  together  in  Italy,  he  wished  to  work,  but  suddenly 
he  felt  himself  struck  with  a  momentary  loss  of  power,  and  fell 
into  one  of  those  cases  of  spleen  against  which  he  did  not  know 
how  to  react  alone.  He  would  be  overcome  by  emotions  coming 
from  without ;  magnificant  music  came  from  the  ceiling ;  an 
Arabian  horse  would  come  in  through  the  key  hole.  It  made  no 
difference  what  delicious  and  terrible  occurrence  which  would 
tear  him  from  himself  and  under  the  impulsion  of  which  he  felt 
exalted  and  renewed.    But  here  is  the  other  period. 

The  days  following  he  did  not  come  home  at  all  at  night — he 
went  out  he  said — in  a  boat  and  exercised  himself  rowing  and 
taking  lessons  from  a  local  fisherman.  He  pretended  to  find  that 
the  fatigue,  which  lessened  the  excitation  of  his  nerves,  was  good 
for  the  work  of  the  afternoon.  But  this  excitation  did  not  con- 
strain him  to  spend  the  entire  night  in  the  boat  of  some  fisherman. 
And  then  Georges  Sand  makes  the  sorrowful  disclosure  of  the 
dipsomania  of  de  Musset. 

"  Has  he  not  said  to  me,  and  alas,  almost  proved  it,  that  I 
smothered  his  genius  in  wishing  to  destroy  his  fever.  When  I 
believed  him  to  have  come  to  the  limit  of  disgust  in  his  excesses, 
have  I  not  seen  that  he  was  anxious  for  more?  When  I  have 
said  to  him  return  to  the  world,  he  feared  my  jealousy,  and  threw 
himself  into  gross  and  mysterious  debaucheries.  He  would  come 
home  drunk,  with  his  clothes  torn  and  his  face  bleeding." 

Is  it  not  a  matter  for  reflection  to  learn  that  the  same  morbid 
symptom  may  show  itself  under  the  aspect  of  a  night  of  orgy,  or 
of  a  night  of  sublime  inspiration,  says  Kahn. 

It  is,  I  believe,  recognized  by  many  at  the  present  time  that 
dipsomania — or  periodic  drunkenness — is  not  by  any  means  al- 
ways an  epileptic  equivalent.  Such  is  by  far  too  narrow  an  in- 
terpretation, and,  in  fact,  I  am  inclined  to  regard  periodic  drunk- 
enness occurring  as  an  epileptic  equivalent  to  be  extremely  un- 
common.   That  such  cases  do  occur  is  unquestioned,  and  they  are 

"  L.  c,  145  and  following. 
"  EUe  et  lui,  p.  56,  Levy. 


CYCLOTHYMIA  20/ 

not  frequent,  but  on  the  other  hand,  periodic  drunkenness  is  a 
common  cyclothymic  manifestation,  as  well  as  a  frequent  compli- 
cation in  a  fully  developed  manic-depressive  psychosis.  I  have 
observed  it  both  in  the  cyclothymic  depressed,  and  in  the  cyclo- 
thymic excited  periods — though  rarely  in  the  same  individual.  Its 
occurrence  in  some  cyclothymic  mixed  states  has  been  commented 
on  by  Dupre,"  and  such  an  interpretation  has  seemed  to  me  justi- 
fiable in  a  few  cases  under  personal  observation. 

My  own  experience  has  been  too  limited  to  offer  any  figures  as 
to  the  tendencies,  but  I  have  seemed  to  encounter  considerable 
quiet  drinking  which  has  brought  many  a  patient  to  the  verge  of 
an  alcoholic  neuritis,  and  even  a  Korsakow  syndrome  in  the  de- 
pressed cyclothymics,  whereas  the  more  boisterous  and  active  de- 
bauches are  found  among  the  hypomanics. 

Sexual  Types. — Closely  allied  with  the  subject  of  periodic 
drinking,  and  often,  though  not  always,  accompanying  it,  the  sub- 
ject of  periodic  sexual  erethism  and  sexual  frigidity  asserts  itself. 

The  acute  mental  disturbances  of  young  brides,  and  the  periodic 
apparent  hypomanic  disorder  found  in  fiances  are  not  here  referred 
to,  Romfeld^*  and  Dost^^  have  discussed  these  questions  fully,  but 
I  refer  to  shorter  or  longer  manifestations  of  abnormal  sexual 
excitement  and  of  sexual  frigidity  which  are  the  expressions  in 
the  sexual  sphere  of  cyclothymic  attacks. 

It  is  far  from  uncommon  to  learn  that  the  loss  of  chastity  and 
conception  has  resulted  to  a  young  woman  whose  self-control 
was  reduced  by  reason  of  her  mental  disorder,  mild  though  it  may 
have  been.  Such  a  distressing  complication  of  a  cyclothymia 
occurs  in  some  of  the  "  best  families."  Again  hasty,  and  some- 
times ill-considered  marriages  have  been  permitted  because  of  ex- 
cessive sexual  excitement  in  some  young  woman  which  excess  has 
been  the  expression  not  of  a  balanced  ardent  nature,  but  of  a  patho- 
logical state,  with  all  the  ear  marks — for  one  who  can  read  the 
little  things — of  a  cyclothymia.  Such  marriages  continue  to 
supply  their  later  stock  of  those  not  only  with  a  cyclothymic  con- 
stitution, but  with  children  who  develop  a  well-marked  manic- 

"  Ballet,  Soc.  de  Neur.  de  Paris,  July  5,  1900;  March  7,  1907.     Soc.  de 
Psychiatric  de  Paris,  March  30,  1903. 
"Zyclothymie  bei  Brauten.  Med. 
"Allge.  Zeits.  f.  Psych.,  54,  1902. 


208  CYCLOTHYMIA 

depressive  psychosis.     Illustrative  cases  can  be  supplied  by  prac- 
tically all  the  members  of  this  association. 

With  this  short  introduction  to  the  general  topic  of  the  mild 
types  of  manic-depressive  psychosis,  or  cyclothymias,  I  leave  the 
subject  for  your  consideration. 


LIST   OF   PAPERS   READ   BEFORE   THE    NEW   YORK 
PSYCHIATRICAL    SOCIETY 

April  I,  1903. 

Discussion  :   "  Infantile  Insanity  in  its  Relation  to  Moral  Perversion 
and  Crime." 
May  20,  1903. 

Discussion  :  "  On  the  Classification  of  Mental  Diseases." 
November  4,  1903. 

No  paper. 
January  6,  1904. 

Paper:  "Plans  for  Psychopathic  Wards  and  Hospitals."     Dr.  Clark. 
March  2,  1904. 

Discussion  :    "  Report  of   the   Committee  on   Classification   of   Mental 
Diseases." 
May  4,  1904. 

Paper  :  "  Fright  as  the  Cause  of  Mental  Disturbances."    Dr.  Bailey. 
November  2,  1904. 

Paper  :  "  Curability  of  General  Paresis."    Dr.  Dana. 
January  3,  1905. 

Paper  :    "  Habit    Disorganization    in    Essential    Deteriorations."      Dr. 
Meyer. 
March  i,  1905. 

Paper  :  "  Mental  and  Nervous  Diseases  in  Classic  and  Pictorial  Art." 
Dr.  Clark. 

Paper:  "Art  Among  the  Insane  and  Degenerate."     Dr.  Dana. 
May  3,  1905. 

Paper:    "The    Mechanisms   of   the    Phenomena   of    Psychopathology." 
Dr.  Hirsch. 
October  4,  1905. 

Paper:  "Drug  Deliria."     Dr.  Hoch. 
December  6,  1905. 

Paper  :  "  Insanity  as  a  Result  of  Hysterectomy  and  Oophrorectomy." 
Dr.   Hammond. 
January  6,  1906. 

Paper  :  "  People  vs.  Wood."    Dr.  Bailey. 
March  7,  1906. 

Paper:  "People  vs.  Young."    Dr.  Hirsch. 
May  2,  1906. 

Paper:  "Plans  and  Policy  for  the  Work  of  the  Coming  Winter."     Dr. 
Meyer. 
November  7,  1906. 

Paper:  "Diagnostic  Criteria  of  General  Paresis."    Dr.  Campbell. 

15  209 


2IO  LIST   OF   PAPERS   READ 

January  2,  1907. 

Paper:   "The   Prognostic-symptomatic    Complex   of   Manic-depressive 
Psychosis."    Dr.  Kirby. 
March  4,  1907. 

Paper  :  "  Psychogenetic  Factors  in  some  Paranoic  States."    Dr.  Hoch 
May  I,  1907. 

Paper  :   "  Recommendations  Concerning  the  Improvement  of  Medico- 
legal methods."     Dr.  Bailey. 
November  6,  1907. 

Paper  :  "  Ocular  Disc  changes  in  Dementia  Prsecox."     Drs.  Clark  and 
Tyson. 

Paper:  "Anxiety  Psychoses."     Dr.  Kirby. 
January  8,  1908. 

Paper  :  "  Psychogenesis  and  Dementia  Prsecox."    Dr.  Hoch. 
March  4,  1908. 

Paper  :   "  The  Relation   of   Hysteria   and    Psychasthenia   to  Dementia 
Praecox."     Dr.  Meyer. 
May  6,  1908. 

Paper  :  "  On  the  Voluntary  Admission  to  State  and  Private  Institu- 
tions."    Dr.  Brooks. 
November  4,  1908. 

Paper  :    "  A    Study    of    the    Mental    make-up    in    different    Functional 
Psychoses."     Dr.  Hoch. 
January  6,  1909. 

Paper  :  "  Etiological  Factors  of  the  Psychoses."    Dr.  Mabon. 

Paper:  "Racial  Psychopathology."     Dr.  Kirby. 

Paper  :  "  Ocular  Reactions  among  the  Insane."     Dr.  Diefendorf . 
March  3,  1909. 

Paper:  "Multiple  Melancholia."     Dr.  Dana. 

Paper  :  "  A  Comparative  Study  of  the  Capacity   for  Mental  work  in 
Dementia  Praecox  and  Alcoholic  Insanity."     Dr.  Cotton. 
May  5,  1909. 

Paper:  "Clinical  Forms  of  Periodic  Drinking."    Dr.  Bailey. 

Paper:  "Contribution  to  the  Etiology  of  Manic-depressive  Insanity." 
Dr.  Hoch. 
November  3,  1909. 

Paper:  "Further  Report  on  Cases  of  Alleged  Cured  Pre-paresis."    Dr. 
Dana. 

Paper  :   "  On   some  Ethical  questions  in   Psychiatrical   Expert  Work." 
Dr.  Hirsch. 
January  5,  1910. 

Paper  :  "  The  Alleged  Increase  of  Insanity."     Dr.  Stedman. 
March  2,  1910. 

Paper  :  "  The  Content  and  Form  of  the  Psychosis  or   Psychoanalysis 
in  Psychiatry."     Dr.  Campbell. 

Paper:  "The  State  Care  of  the  Dangerorsly  Insane."     Dr.  Hammond. 
April  27,  1 910. 


LIST   OF   PAPERS   READ  2  I  I 

Paper  :  "  A  Case  of  Malingery."     Dr.  Cotton. 
November  2,  1910. 

Paper:  "The  Insane  in  Japan."    Dr.  Peterson. 

Paper  :    "  Cyclothymia, — the    Mild    Forms   of    Manic-depressive    Psy- 
chosis."   Dr.  Jelliffe. 


THE  EYE  SYNDROME  OF  DEMENTIA  PRECOX 

Ocular  Signs  and  Symptoms  of  Dementia  Precox  and  their 
Significance,  as  Observed  in  115  Consecutive  Cases^ 

By  H.  H.  Tyson,   M.D. 
surgeon,  n.  y.  ophthalmic  and  aural  institute,  new  york  city 

AND 

L.  Pierce  Clark,  M.D. 

SENIOR    ATTENDING    PHYSICIAN,    HOSPITAL   FOR   NERVOUS   DISEASES,    OF 
NEW    YORK    CITY,    NEW    YORK 

In  1899,  Seglas  saw  a  case  of  anxious  melancholia,  followed 
by  mental  confusion,  evolve  parallel  with  gastro-intestinal  auto- 
intoxication. Meyer  reported  five  similar  cases.  The  idea  that 
dementia  prsecox  is  an  autotoxic  disease  originated  with  Morro, 
who  first  connected  hebephrenia  with  this  cause  in  1900.  The 
evidence  for  its  autotoxic  nature  may  be  grouped  as  follows : 
(i)  There  is  a  coincidence  of  certain  ocular  symptoms  with  gas- 
trointestinal autointoxication  similar,  in  many  aspects,  to  those 
seen  in  typhoid,  lead  colic,  and  simple  intestinal  putrefaction. 
(2)  The  urine  in  dementia  praecox  shows  very  defective  elimina- 
tion. (3)  Fully  one-half  of  the  subjects  of  dementia  praecox 
die  of  tuberculosis.  (4)  The  co-existence  of  certain  toxic  derma- 
toses, such  as  certain  types  of  erythema,  vasomotor  paresis,  with 
chronic  gastrointestinal  intoxication,  is  noteworthy.  (5)  Some 
additional  facts  are  at  hand,  as  shown  in  the  co-existence  of 
psychic  excesses,  neurasthenia,  etc.,  with  states  of  autointoxica- 
tion. (6)  The  study  of  the  blood  in  dementia  praecox  shows 
evidence  of  a  toxic  state. 

'This  work  was  undertaken  at  the  suggestion  of  Dr.  Clark  and  the 
greater  part  of  the  work  was  carried  out  in  his  service  at  the  Manhattan 
State  Hospital  and  at  the  Vanderbilt  Clinic  (Dr.  Starr's  service).  Dr. 
Tyson  made  the  eye  examinations  and  is  responsible  for  the  detailed  find- 
ings of  the  same.  Both  authors  are  jointly  responsible  for  the  interpreta- 
tive significance  of  the  study. 

212 


THE    EYE    SYNDROME    OF    DEMENTIA    PR.ECOX  2I3 

More  specific  evidence  is  at  hand  in  Kuhnt  and  in  Blin's  work, 
especially  the  latter.  In  1905  Blin  published  a  monographic  con- 
sideration of  the  autotoxic  nature  of  dementia  prascox.  He  at- 
tempted to  show  that  the  retinal  changes  are  analogous  to  those 
seen  in  various  acute  and  chronic  infections.  It  is  of  passing  his- 
toric interest  to  say  that  Dide  and  Assicot  (1901)  had  already 
noted  the  alteration  of  anemia  and  congestion  in  the  discs  of 
dementia  praecox.  None  of  these  various  observers  have  made 
any  thorough  or  systematic  attempt  to  analyze  the  significance  of 
the  eye  changes  in  dementia  praecox. 

The  subject  of  the  ophthalmoscopic  changes  in  dementia  prae- 
cox receives  little  attention  in  the  most  recent  reference  works. 
Our  bibliographic  research  has  unearthed  but  two  studies  in  which 
the  subject  is  considered.  These  are  the  general  papers  by  Kuhnt 
and  Wochenin  on  alterations  in  the  retina  in  psychoses,  and  the 
work  by  Blin  on  the  ocular  changes  in  dementia  praecox.  Kuhnt 
and  Wochenin-  examined  511  cases  of  mental  diseases  with  the 
ophthalmoscope.  Of  these  there  were  5  cases  of  hebephrenia. 
The  other  forms  of  dementia  praecox  arc  not  mentioned.  Patho- 
logic changes  in  but  one  case  are  mentioned,  presumably  the 
others  were  not  noteworthy.  This  one  patient  had  pallor  or 
anemia  of  the  temporal  half  of  the  papilla. 

The  work  of  BHn  is  much  more  to  the  point.  He  examined 
the  retina  in  87  cases  of  dementia  praecox.  A  second  examination 
was  frequently  undertaken.  Despite  his  extensive  material,  Blin 
appears  to  have  made  no  careful  analysis  of  the  significance  of 
the  findings.  Of  the  87  cases,  some  abnormality  of  the  papillae 
was  found  in  59.  The  material  was  divided  into  three  groups. 
Nine  cases  (10.2  per  cent.)  showed  constant  hyperemia  of  the 
discs,  and  in  23  (36.8  per  cent.)  the  congestion  was  transitory. 
Blin  does  not  mention  the  condition  of  the  blood  vessels  as  to 
overfilling,  tortuosity,  etc.,  nor  does  he  appear  to  have  examined 
closely  into  the  coincident  eye  symptoms  necessary  to  establish  an 
eye  syndrome  for  dementia  praecox.  An  anemia  of  the  papillae 
was  constant  in  7  cases  (8  per  cent.),  and  inconstant  in  15  (25.3 
per  cent.).    He  uses  the  term  intermittent  in  connection  with  the 

'Ueber  Veriinderungen  der  Netzhaut  bei  Geisteskrankheiten,  Ztschr. 
f.  Augenh.,  1903,  xiii,  89. 


214  "^^^    ^^^    SYNDROME    OF    DEMENTIA    PRECOX 

latter.  There  were  5  cases  in  which  congestion  alternated  with 
anemia  (5.74  per  cent.). 

Various  points  often  mentioned  in  individual  cases  are  not 
summed  up,  such  as  haziness  of  the  border,  or  the  absence  of 
demarcation  between  papillae  and  retina,  predominance  of  lesion 
in  one  eye,  and  the  like.  Doubtless  all  these  facts  seemed  some- 
what contradictory  and  did  not  lend  themselves  easily  to  a 
summary. 

Three  years  ago  we  undertook  an  independent  research  on 
the  significance  of  the  ocular  signs  and  symptoms  in  dementia 
praecox.  We  have  analyzed  115  consecutive  cases.  The  work 
was  undertaken  with  the  view  that  a  careful  analysis  of  the  eye 
symptoms  in  dementia  praecox  might  throw  some  definite  light  on 
the  uncertain  and  perplexing  pathogenesis  of  the  disorder.  In 
this  respect,  we  believe  we  have  not  been  disappointed,  inasmuch 
as  we  have  found  definite  changes  and  symptoms  in  all  cases  which 
are  fully  distinctive  of  this  psychosis. 

The  fundus  changes  as  seen  clinically  may  be  divided  into 
three  groups,  which  are  usually  in  the  order  of  their  occurrence, 
as  follows: 

1.  Congestion  of  discs;  hyperemia  and  edema;  dilated,  dark 
colored  veins;  slightly  contracted  arteries  and  blurring  of  the 
edges  of  the  discs,  all  varying  in  degree.  These  changes  consti- 
tute a  low  grade  of  perineuritis  of  the  optic  nerve. 

2.  Congestion  of  the  nasal  side,  with  temporal  pallor  of  discs, 
dilated  veins,  contracted  arteries. 

3.  Pallor  of  discs,  dilated  veins,  contracted  arteries.  These 
changes  constitute  anemia  and  partial  atrophy  of  the  optic  nerve. 

One  hundred  and  nine  cases  were  examined  with  the  ophthal- 
moscope; 55  were  males  and  54  females.  The  ages  of  the  males 
were  from  12  to  47  years,  and  those  of  the  females  were  from  13 
to  39  years. 

All  the  different  forms  of  dementia  praecox  were  under  study. 
While  the  results  by  form  types  have  not  been  fully  analyzed,  we 
are  prepared  to  say  that  the  more  marked  changes  in  the  eye  syn- 
drome were  found  in  the  more  rapidly  deteriorating  types  of 
dementia  praecox. 

The  cases  embrace  those  who  have  used  alcohol  and  tobacco 
moderately  or  to  excess,  as  well  as  abstainers.    It  is  possible  that 


THE    EYE    SYNDROME    OF    DEMENTIA    PILECOX  21 5 

alcohol  and  tobacco  have  contributed  toward  the  clinical  picture 
in  some  cases.    In  differentiating  the  pathologic  condition  of  the 
optic  nerve  in  tobacco  and  alcohol  users  from  those  in  cases  of 
dementia  prsecox,  one  observes  central  scotoma  in  the  former. 
The  one  case  showing  a  central  scotoma  for  red  in  dementia  prae- 
cox  gave  a  history  of  alcohol  and  tobacco  excesses.     The  disc 
changes  in  dementia  praecox  have  some  resemblance  to  those  seen 
in  the  toxic  amblyopia  of  tobacco  and  alcohol.     But  the  fundus 
changes  above  detailed  are  seen  in  all  cases  under  study.    There 
is  strong  evidence  that  some  other  potent  toxin  is  responsible  for 
the  disc  changes  in  dementia  praecox.    We  do  not  hesitate  to  say 
that  we  believe  the  toxin  is  primarily  a  vascular  poison.    Its  most 
probable  source  is  in  the  autointoxication  (intestinal  putrefaction 
is  almost  invariably  evident  from  clinical  symptoms)   from  the 
intestines  or  from  the  liver.     It  is  possible  that  a  faulty  metab- 
olism from  a  perverted  action  of  some  of  the  ductless  glands 
(thyroid  especially)  may  be  the  pathogenic  agent.     The  primary 
departure  from  the  normal  in  the  disc  is  in  the  veins.     They 
become  dilated,  tortuous  and  darker  than  normal.    Edema  of  the 
disc  appears  shortly  afterward.    These  changes  are  analogous  to 
those  seen  in  the  passive  congestion  of  the  face  and  hands  in 
dementia  praecox  cases.     All  these  edemas  produce  such  lasting 
disturbance  in  the  nutrition  of  the  optic  nerve  that  slow  degenera- 
tion of  the  nerve  fibers  finally  results.     Thus,  of  the  109  cases 
examined  by  the  ophthalmoscope  a  low  grade  perineuritis  was 
found  62  times  in  the  right  eye  and  67  times  in  the  left.    Temporal 
pallor,  with  nasal  side  congested,  was  found  in  the  right  eye  10 
times,  in  the  left  eye  11  times.    Pallor  of  discs  was  found  in  the 
right  eye  in  37  cases  and  in  the  left  eye  in  31  cases. 

Inasmuch  as  the  disc  changes  in  the  first  stages  resemble  some- 
what those  seen  in  ordinary  intestinal  toxemia,  we  have  repeatedly 
examined  the  discs  in  a  number  of  cases  while  the  patients  were 
under  active  hygienic  treatment  of  free  catharsis,  intestinal  anti- 
septics, baths  and  dietetic  regulations.  A  marked  degree  of  bet- 
terment was  noticed  of  the  congestive  margins  of  the  discs,  but 
the  central  edema  and  transitional  pallor  have  continued.  Indeed, 
while  patients  were  under  this  treatment  a  general  physical  im- 
provement was  noticed  but  the  mental  state  seemed  little  im- 
proved. 


2l6  THE    EYE    SYNDROME    OF    DEMENTIA    PRECOX 

Coincident  with  the  study  of  the  changes  in  the  papillae,  the 
pupils  were  examined  in  85  cases.  The  changes  uniformly  found 
here  were  not  less  significant.  The  examinations  were  made  in 
moderately  light  rooms  with  the  eyes  fixing  a  distant  object.  The 
size  of  the  pupils  varied  from  3^  mm.  to  7  mm.,  with  an  average 
of  4'^%5  mm.,  while  the  average  of  the  control  pupils  (physician 
and  attendants)  was  3^%5.  An  average  enlargement  of  i%5  mm. 
for  dementia  praecox  over  the  normal  was  evident. 

The  light  reaction  was  normal  in  71  cases  and  sluggish  in  14. 
Consensual  reaction  was  active  in  68  cases  and  sluggish  in  17 
cases. 

Accommodation  and  convergence  were  active  in  71  cases  and 
sluggish  in  13.    Hippus  was  present  in  one  case. 

The  sensory  pupillary  reflex  was  slightly  positive  in  6  cases 
and  negative  in  79  instances.  The  psychic  reflex  was  sHghtly 
positive  in  4  cases  and  negative  in  85  cases.  Piltz-Westphal  reflex 
was  positive  in  2^  and  negative  in  85  cases. 

Great  care  was  exercised  in  measuring  the  pupils  on  account 
of  the  tendency  of  the  eyes  to  change  their  visual  lines.  One  is 
apt  to  complicate  the  accommodation  and  convergence  reflex  with 
the  other  tests.  The  negative  reactions  of  the  pupil  appear  to  be 
due  ( I )  to  loss  or  partial  loss  of  function  through  defective  nerve 
innervation;  (2)  defect  in  attention ;  (3)  diminished  apperception. 

Corneal  sensibility  was  diminished  in  69  cases  and  normal  in  17. 

The  visual  color  fields  were  examined  in  81  cases.  All  were 
found  concentrically  contracted.  The  largest  field  was  30  degrees, 
the  smallest  o  degrees.  The  fields  were  practically  abolished. 
The  average  of  the  81  cases  was  10.6  degrees,  which  was  a  marked 
contraction  from  the  normal.  This  may  be  explained  partially  by 
the  inattention  of  those  patients,  diminished  capacity  for  exter- 
nalization  and  finally,  and  not  least,  by  the  edema  and  congestion 
of  the  optic  nerve  (perineuritis)  in  the  first  stage  of  degeneration 
of  the  nerve  and  by  the  ultimate  shrinkage  of  the  new  connective 
tissue  in  the  partial  atrophy  of  the  nerve. 

The  changes  in  the  discs,  pupils,  visual  fields  and  corneal  sen- 
sibility which,  when  taken  together,  constitute  the  new  syndrome, 
are  all  in  accord  with  each  other.  In  our  examination  of  all  other 
types  of  insanity,  imbecility  or  idiocy  we  have  found  no  other 

'  At  first  positive,  later  examination  was  negative. 


Fig.  I.  A.  B.,  "DP."  26  years  old,  two 
years  in  Manhattan  State  Hospital.  Wards 
Island.  Left  eye  shows  congestion  and 
edema  of  entire  disc,  edges  blurred  and 
indistinct,  filling  in  of  physiological  exca- 
vation. Veins  dilated,  dark  and  tortuous; 
relative  size  compared  to  arteries,  2I  to  i. 
(Direct  method  of  examination.) 


Fig.  2.  K.  M.,  "DP,"  in  Manhattan 
State  Hospital  for  13  months.  Quite  de- 
teriorated. Right  eye  shows  temporal  pallor, 
with  nasal  congestion  and  edema,  blurring 
of  edges  on  the  nasal  side.  Veins  dark  and 
tortuous,  dilated ;  relative  size  of  veins  to 
arteries,  2  to  i.  (Direct  method  of  exami- 
nation.) 


Fig.  3.  M.  E.,  "  DP."  Right  eye.  Shows 
pallor  of  entire  disc.  Edges  blurred  and 
indistinct.  Veins  dilated,  dark  and  tortuous. 
-Arteries  slightly  contracted.  Relative  size, 
compared  to  arteries,  2  to  i.  (Direct 
method  of  examination.) 


THE    EYE    SYNDROME    OF    DEMENTIA    PRECOX  21/ 

condition  similar  to  what  we  have  outHned  here  for  dementia 
prascox. 

The  dinical  significance  of  these  findings  is  of  importance: 

1.  They  indicate  that  dementia  praecox  is  attended  by  such 
an  early  and  constant  syndrome  of  alteration  and  disc,  visual  field, 
pupil  and  corneal  sensibility  as  to  materially  aid  in  diagnosticating 
this  psychosis.  Consideration  of  the  syndrome  will  particularly 
aid  in  the  diflferential  diagnosis  of  dementia  praecox  from  the 
manic-depressive  group,  acquired  neurasthenia,  hysteria  and  the 
various  forms  of  imbecility  and  constitutional  inferiority. 

2.  The  syndrome  is  a  distinct  contribution  to  the  theory  that 
dementia  praecox  is  an  autotoxic  disease,  and  that  the  poison  is 
primarily  vascular,  which  finally  induces  neuronic  degeneration. 
It  points  to  a  toxin  of  some  sort,  which  is  either  a  metabolic  defect 
in  the  tissues  (ductless  gland  defect)  or,  what  seems  more  prob- 
able, that  the  poison  is  generated  in  the  liver  or  in  the  gastro- 
intestinal tract  itself. 

3.  The  syndrome  is  of  prognostic  value,  as  the  severer  grades 
of  eye  changes  are  found  in  the  more  rapidly  deteriorating  cases. 

4.  Finally,  the  optic  nerve  lesion  is  quite  in  accord  with  our 
best  knowledge  of  the  pathologic  anatomy  of  dementia  praecox,  in 
other  tracts  of  the  brain  (than  the  optic  nerve  which  itself  may 
be  counted  an  analogue).  The  early  vascular  changes  in  the  brain 
ought  to  receive  more  serious  investigation. 

We  desire  to  thank  Dr.  Mabon  and  his  staflF,  Dr.  Smith  of 
Central  Islip  and  his  staflf,  and  the  staff  of  assistants  in  the  neuro- 
logic department  of  the  Vanderbilt  Clinic  (Dr.  Starr's  service) 
and  Dr.  C.  E.  Atwood  in  particular,  for  the  courtesies  extended 
to  us  in  placing  their  patients  at  our  command. 

Since  the  publication  of  our  original  paper  upon  the  eye  syn- 
drome of  dementia  prascox  no  similar  carefully  recorded  observa- 
tions upon  the  subject  have  been  made.  It  is  true,  however,  that 
the  fundamental  postulate  of  the  cause  of  the  syndrome,  namely, 
the  toxic  character  of  the  mental  disorder,  has  been  under  con- 
tinuous study.  The  rival  camps  of  a  psychic  or  somatic  origin 
for  the  disease  have  been  in  a  constant  state  of  warfare.  The 
attitude  of  the  Kraepelinian  school  of  somatists  and  the  Meyer- 
Hoch  school  of  psychogenists  are  too  well  known  for  us  to  detail 
the  special  viewpoints  of  each  here.     It  is  hoped  a  mutually  sup- 


2l8  THE    EYE    SYNDROME    OF    DEMENTIA    PRECOX 

portive  middle  ground  may  succeed  the  present  day  partisanship. 

The  main  contention  of  our  paper  is  that  a  fairly  constant  eye 
syndrome  exists  in  dementia  praecox,  and  secondly  the  best  hypoth- 
esis for  explaining  the  presence  of  the  same  is  upon  some  endog- 
enous or  exogenous  toxic  substance.  We  believe  the  first  posi- 
tion has  been  established.  From  the  partial  and  incomplete  nature 
of  our  study  the  second  contention  can  only  be  urged  as  a  con- 
tributing study  to  that  end. 

It  is  unnecessary  to  point  out  the  remarkably  low  resistance 
of  nerve^issue  to  toxins  in  dementia  prsecox.  As  is  well  known 
in  ophthalmic  practice,  degenerative  changes  in  the  nerve  head 
from  toxins  are  at  first  transitory,  requiring  time  for  producing 
distinct  pathological  changes  as  shown  exquisitely  in  tobacco  ambly- 
opia. Even  then  such  fundus  changes  are  apparently  slight  and 
not  recognizable  microscopically  but  should  be  by  more  delicate 
methods  of  analysis.  The  extra  vulnerability  of  nervous  tissue  in 
dementia  praecox  may  be  fairly  well  shown  in  a  kindred  state  of 
inherited  vice  of  constitution,  that  of  imbecility.  In  a  study  of 
the  eye  in  mental  defectives  by  Clark  and  Cohen,*  one  of  the 
objects  of  the  study  was  to  note  whether  a  parallelism  in  consti- 
tutional defect,  namely  a  strong  tendency  to  neural  degeneration, 
existed  in  both  disorders.  It  is  interesting  to  note  in  this  connec- 
tion that  the  authors  found  fully  three  fourths  of  all  cases  of 
idiocy  of  their  study  showed  varying  degrees  of  retrobulbar  neuri- 
tis of  a  degenerative  character.  However  one  may  search  for 
exciting  causes  in  the  degeneration  of  the  optic  nerve  in  idiocy  or 
dementia  prsecox,  one  needs  to  bear  in  mind  that  parallelism  prob- 
ably extends  no  further  than  an  inherent  tendency  in  both,  for 
the  development  and  character  of  the  changes  in  each  are  totally 
unlike.  Then,  too,  defectives  never  have  the  pupillary  or  other 
signs  of  the  eye  syndrome  of  dementia  praecox. 

In  examining  the  fundus  of  the  eye,  allowance  must,  of  course, 
be  made  for  each  individual  variation  within  relatively  wide 
physiological  limits.  The  difference  in  appearance  of  the  fundi 
in  anemic  individuals  and  well  nourished  ones  is  not  inconsider- 
able.    The  same  relative  disproportion  in  sizes  of  arteries  and 

*  A  Study  of  the  Eye  in  Mental  Defectives,  Journal  of  American 
Medical  Association,  April  i6,  igio,  Vol.  LIV,  pp.  1287,  1288. 


THE    EYE    SYNDROME    OF    DEMENTIA    PRECOX  219 

veins  exists  in  most  all  cases  while  the  actual  calibre  of  vessels 
varies  greatly. 

As  to  the  different  stages  of  the  fundus  changes  since  study- 
ing our  cases  over  a  longer  period  of  observation,  it  is  a  question 
with  us  whether  our  first  and  second  stages  should  not  be  trans- 
posed. As  is  well  known  and  first  pointed  out  by  Horsley,  in 
choked  disc  from  brain  tumor,  the  earliest  changes  are  found  in 
haziness  of  the  superior  nasal  quadrant  of  disc.  But  as  in  the 
examination  of  the  early  cases  examined  at  the  clinics  (prehos- 
pital or  preasylum  stage)  we  noted  a  majority  of  the  congestive 
stage,  i.  e.,  entire  disc  congested,  etc.,  as  originally  described  in 
stage  No.  i. 

Size  of  pupils :  Those  which  were  less  than  the  normal  average 
were  taken  in  bright  light  and  were  included  so  as  to  account  for 
and  make  a  total  average  for  all  our  cases  examined,  otherwise 
if  the  average  size  of  pupils  were  considered  only  of  those  that 
had  been  measured  in  a  moderately  lighted  room  as  the  majority 
had  been,  then  the  average  size  would  have  been  a  trifle  larger 
than  reported. 

Great  care  needs  to  be  exercised  in  testing  sensibility  of  cornea ; 
one  should  not  touch  eyelashes,  nor  lids,  nor  have  image  of  ap- 
proaching objects  or  test  fall  on  visual  field.  One  should  care- 
fully approach  the  cornea  from  the  periphery.  Additional  cases 
making  200  in  all  have  been  examined  and  about  the  same  per- 
centage of  changes  have  been  found  as  were  observed  in  the  115 
first  reported. 

Examination  of  fundi  of  dementia  prsecox  cases  by  Dr.  Hol- 
den,  subsequent  to  our  examinations,  changes  were  noted  by  him 
in  about  fifty  per  cent,  of  cases ;  but  he  did  not  study  the  syndrome 
in  its  entirety.  He  confined  himself  entirely  to  examination  of 
fundi  alone. 

The  recent,  careful  and  rather  exhaustive  work  of  Southard 
upon  dementia  praecox  is  worthy  of  more  than  passing  notice. 
Southard  made  a  careful  examination  of  62,  brains  obtained  from 
dementia  prsecox  patients  who  died  at  the  Danvers  (Mass.)  State 
Hospital.  In  his  investigations  he  laid  particular  stress  on  the 
"topographic  idea"  which  had  occurred  to  him,  when,  some  years 
ago,  he  made  an  analysis  of  the  first   1,250  necropsies  of  the 


220  THE    EYE    SYNDROME    OF    DEMENTIA    PRECOX 

Danvers  State  Hospital  and  collected  the  lesions  of  different  parts 
of  the  brain  in  card  catalogue  form.  In  a  surprisingly  large  num- 
ber of  cases  he  found  local  areas  of  sclerosis,  atrophy  or  aplasia. 
His  conclusions  in  regard  to  dementia  prsecox  are  as  follows : 

"  I.  Existent  evidence  for  the  organic  nature  of  dementia 
praecox  is  not  wholly  convincing,  since  (a)  the  cytologic  changes 
described  are  found  also  in  cases  of  toxic  deliria  and  in  cases 
complicated  by  severe  visceral  disease,  and  (b)  the  stratigraphic 
changes  described  are  found  also  in  senile  cases  without  charac- 
teristic symptoms  of  dementia  prgecox. 

2.  Resort  must,  therefore,  be  had  to  the  topographic  idea,  for 
the  adequate  exploitation  of  which  total-brain  sections,  with  cyto- 
logic exploration  of  all  areas,  are  ideally  necessary. 

3.  Random  blocks  of  brain  tissue  with  demonstration  of  satel- 
litosis,  infrastellate  gliosis,  or  disintegration  products  of  cell  dis- 
order will  throw  little  light  on  the  mechanism  of  dementia  praecox. 

4.  The  data  of  the  functionalists  (dissociation,  sejunction, 
intrapsychic  ataxia,  and  the  like)  are  of  the  utmost  importance  as 
indicating  the  essential  focality  of  the  pathogenic  process  and 
the  focal  variations  in  its  severity. 

5.  The  curability  of  certain  cases,  the  remissive  character  of 
some  cases,  the  speedy  disappearance  of  particular  symptoms,  the 
persistent  complexity  of  reaction  in  some  instances,  the  absence 
of  characteristic  severe  projection-system  symptoms,  all  indicate 
that  the  process  is  histo-pathologically  mild  and  that  the  focal 
changes  found  will  be  found  but  slightly  destructive  or  even  irri- 
tative (in  the  sense  of  slight  injuries  readily  repaired  or  compen- 
sated for). 

6.  Grossly  destructive  lesions  of  a  transcortical  character  in 
Wernicke's  sense  might  conceivably  effect,  e.  g.,  a  permanent  cata- 
tonic complex  and  doubtless  will  be  found  to  do  so  occasionally ; 
but  the  protean  and  progressive  character  of  dementia  praecox  will 
exclude  such  transcortical  injuries  from  playing  a  large  part  in 
the  pathogenesis. 

7.  The  focal  lesions  to  be  sought  for  will  doubtless  escape 
macroscopic  notice  in  many  instances,  since  the  volume  of  appara- 
tus engaged  in  affecting  very  prominent  symptoms  is  often  slight 
and  is  spread  very  thin  in  numerous  areas. 


THE    EYE    SYNDROME    OF    DEMENTIA    PRECOX  221 

8.  Studies  of  the  "  soft  brain  "  and  of  gliosis  in  epilepsy  have 
proved,  however,  that  even  comparatively  slight  degrees  of  cor- 
tical gliosis  can  often  be  palpated  at  autopsy. 

9.  Palpable  glioses  of  a  focal  or  variable  character  combine  in 
numerous  instances  with  visible  atrophy  and  microgyria,  have 
been  found  in  over  half  the  series  under  examination,  in  cases 
regarded  as  clinically  above  reproach,  and  not  subject  to  coarse 
wasting  processes,  focal  encephalomalacia,  cortical  arterioscle- 
rosis, or  diffuse  chronic  pial  changes. 

10.  The  frequent  co-existence  of  several  foci  of  sclerosis  or 
atrophy  in  the  same  brain  and  the  microscopic  observation  of 
milder  degrees  of  nerve-cell  disorder  and  gliosis  in  regions  with- 
out gross  lesions  tend  to  the  conception  that  the  agent  is  more 
general  and  diffuse  in  its  action  than  would  seem  at  first  sight,  so 
that  future  research  may  well  demonstrate  that  certain  instances  of 
coarse  brain  wasting  and  even  of  diffuse  chronic  leptomeningitis 
belong  to  the  group  (microscopic  corroboration  necessary  for 
assigning  values  to  focal  variations). 

11.  The  microscopic  examination  of  the  residue  of  cases  in 
which  gross  lesions  or  anomalies  were  not  described,  shows  the 
same  tendency  to  gliosis  and  satellitosis  in  numerous  instances  and 
the  same  tendency  to  focal  variations  from  gyrus  to  gyrus  exhib- 
ited by  the  gross  lesion  group.  These  findings  suggest  that  the 
minor  gross  lesions  and  anomalies  of  several  cases  actually 
escaped  notice  (the  protocols,  though  drawn  up  with  a  certain 
system,  are  by  various  hands)  at  autopsy,  so  that  the  probable 
actual  proportion  of  gross  lesions  is  68  per  cent.  If  microscopic 
evidence  is  resorted  to,  the  organic  proportion  in  our  series  rises 
to  86  per  cent. 

12.  Several  groups  of  cases  were  classified  from  the  distribu- 
tion of  microscopic  lesions,  although  the  focal  purity  of  these 
cases  can  often  be  brought  in  question  from  the  results  of  micro- 
scopic examination  (infrastellate  gliosis  and  satellitosis  also  in 
macroscopically  normal  areas). 

I.  Pre-Rolandic  group,  including  a  superior  frontal-prefrontal 
sub-group  of  paranoidal  trend. 

II.  Post-Rolandic  group,  including  (a)  postcentral-superior 
parietal  (sensory  perceptual)  sub-group  in  which  catatonic  fea- 
tures are  the  common  factors;  (b)  occipital  sub-group. 


222  THE    EYE    SYNDROME    OF    DEMENTIA    PRECOX 

III.  Infra-Sylvian  group  (too  small  for  clinical  correlations). 

IV.  Cerebellar  group  (catatonic  features). 

13.  If  these  data  find  general  confirmation,  they  will  doubtless 
go  far  to  unify  discussion,  since  mild,  variable  and  progressive 
intracortical  lesions,  proceeding  at  different  rates  in  different 
parts  of  the  apparatus,  and  having  the  peculiar  distributions  indi- 
cated above  would  explain  adequately  some  of  the  contentions  of 
the  dissociationists,  while  remaining  not  wholly  inconsistent  with 
Kraepelinian  ideas. 

14.  The  frontal-paranoid  correlation  is  in  line  with  modern 
physiologic  ideas,  but  it  must  be  granted  that  the  occipital  and 
temporal  regions,  as  elaborating  important  long-distance  impulses, 
may  well  play  a  part  also  in  paranoid  states. 

15.  The  cerebellar-catatonic  correlation  is  doubtless  in  line 
with  some  contentions  of  the  Wernicke  school,  and  obvious  com- 
ments might  be  made  in  connection  with  the  proprioceptive  func- 
tions of  the  cerebellum  (Sherrington). 

16.  The  post-central-superior-parietal  relations  to  catatonic 
symptoms  are  perhaps  theoretically  the  most  novel  suggestion 
from  the  work,  but  here  again  the  results  are  not  consistent  with 
modern  physiology. 

17.  The  topographic  study  of  dementia  praecox  brains,  both 
gross  and  microscopic,  is  commended  as  likely  to  shed  new  light 
on  the  pathogenesis  of  certain  symptoms,  notably  paranoidal  and 
catatonic  symptoms." 

These  conclusions  of  Southard's  are  given  at  length  not  only 
as  they  are  undoubtedly  the  best  summary  of  the  "  topographic 
study "  of  the  praecox  brain  at  present  hand,  but  because  the 
lesions  of  atrophy  and  sclerosis  are  suprisingly  analogous  for  that 
we  note  in  the  progressive  degenerations  in  the  nerve  head  itself. 
Our  work  might  therefore  be  properly  called  a  clinical  contribu- 
tion to  Southard's  "  topographical  histo-pathological  study."* 

"Our  special  thanks  are  due  to  Dr.  Brun  for  his  faithful  drawings, 
in  color,  of  the  eye  grounds  in  our  cases.  Drawings  are  a  part  of  the  orig- 
inal contribution. 


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